Inspection on 10/01/06 for Convent Society Of The Holy Child Jesus The

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Convent Society Of The Holy... 03/04/07

Convent Society Of The Holy... 13/06/05

Convent Society Of The Holy... 07/12/04

Convent Society Of The Holy... 20/05/04

Convent Society Of The Holy... 09/12/03

Convent Society Of The Holy... 26/06/03

Convent Society Of The Holy... 14/06/02

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Convent Society Of The Holy Child Jesus The The Convent 35 Oatlands Drive Harrogate North Yorkshire HG2 8PU Lead Inspector Mary Slattery Unannounced Inspection 10th January 2006 09:45 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 Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Convent Society Of The Holy Child Jesus The Address The Convent 35 Oatlands Drive Harrogate North Yorkshire HG2 8PU 01423 819667 01423 883983 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) Cornelia Connelly Trustees Incorporated Mrs Paula C Gratton Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: The care home with nursing once know as the Infirmary is linked to the Convent both physically and spiritually and provides personal and nursing care for up to 22 Sisters of the Society. Only the Sisters of the Order are entitled to reside at the home. It is unique in its kind as no care manager becomes involved in the placement of the Sisters. It is a non-profit organisation and is funded by the Cornelia Connelly Trust. The aim of the Convent is to enable the Sisters to live out their religious commitment and to provide care to meet their physical, medical, and social, emotional and spiritual needs. The Convent is located in a residential area of Harrogate and is within easy reach of the town centre. The Convent is situated in its own private grounds and has a large well-laid garden with pleasant views of the countryside. There is ample parking for visitors and staff. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 10th January 2006. The inspection took four and a half hours plus 2 hours preparation time. A tour of the premises was carried out, which included private accommodation. Time was spent observing the activity in the home, talking and listening to the Sisters to establish if they were satisfied with the care and support they received. Time was also spent talking to a number of the staff on duty to discuss their roles and responsibilities and their experiences of being part of a team responsible for providing care to the Sisters. The registered manager and the deputy manager were available throughout the inspection and the findings were discussed and agreed at the close of the inspection. What the service does well: The staff gather good information about the Sisters before they move into the home and develop robust care plans with the Sisters to make sure that there are good plans in place to meet their physical, social, emotional and spiritual needs. They operate a named nurse and key worker system to make sure that each Sister is given the time and support necessary on a daily basis to live their life as they wish, keep their religious observance and have the personal and nursing care they need. They make arrangements for the Sisters to enjoy activities in the local community and in the home these include active and passive exercises, reflexology, shopping and visits to the cinema. Staff are employed in sufficient numbers and there is a staff training and development plan in place. A wide range of equipment to assist people with their mobility is provided and there is a programme for the upkeep and continual refurbishment of the premises in place. All of the Sisters spoken with praised the staff and said that they had no complaints. Staff were observed speaking to the Sisters in a respectful manner and attending to their individual needs as necessary. The staff said they enjoyed working in the home and enjoyed working as a team. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The Sisters are provided with considered information about what the home provides. EVIDENCE: The Convent is well know throughout the Society and the Statement of Purpose and the service user guide gives information about what is provided. The arrangements for admission are between the provincial superior and the Sister and all contracts are agreed individually. The Society employs the services of a nurse to work in the community and where it is identified that a Sister may need the services of the Convent, arrangements are made for an assessment to be carried out by the manager and/or deputy manager. In the event of an emergency admission, a full assessment would be carried out as soon after admission as possible. This was the case at the time of the inspection. The Sisters are welcome to visit the Convent at any time to assess the quality and the services provided before moving in. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 11. There are systems in place for the Sisters to administer their own medication and to be involved in all matters relating to their care. EVIDENCE: Following the initial assessment and taking into consideration the wishes of the Sister, arrangements are put in place for them to administer their own medication. They are provided with locked facilities to keep medication stored safely. The monitored dosage medication system is used and the qualified nurses are responsible for all aspects of the process. Gaps were found in the medication administration records and some of the nursing staff were not using the codes correctly. The policies and procedures in place to provide care at the time of death are in place and observed by staff. The Sisters wishes concerning their care and arrangements after death are discussed and carried out in accordance with their religious beliefs. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15. The Sisters are able to make decisions about their lives, keep contact with family and friends and have good food in pleasant surroundings. EVIDENCE: The home provides an environment, which enables the Sisters to live out their religious commitment and to exercise their rights to dignity and freedom according to their wishes, abilities and beliefs. Some of the choices they make are personal ones but others will be for the good of the whole community. The planning of the menu is following consultation with individuals, considering likes and dislikes and specific dietary needs. The menu looked at showed that a wide variety of nutritious food is provided using fresh produce where possible. Meal times are in accordance with the times that Mass is held. Breakfast can be taken in the dining room area, in their own rooms and lunch and supper are taken in the dining room. Where Sisters are not able due to health reasons to go to the dining room, staff are available to assist them. The staff take their lunch and supper in the dining room with the Sisters. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Staff are available to listen to any concerns the Sisters may have and information about how to make a formal complaint is provided. EVIDENCE: The home has a relevant complaints procedure in place and all complaints are dealt with according to the procedure. There have been no recent complaints made against the service. The required checks are carried out on all staff prior to them taking up their post. A number of staff have attended abuse awareness training and are familiar with the Whistle Blowing procedure. They would benefit from obtaining a copy of the local authorities policy and procedure for the protection of vulnerable adults and to become familiar with the procedure for reporting any allegation or suspicion of abuse in line with the procedure. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22 and 24. The standard of the environment is good providing the Sisters with a bright, clean, homely place in which to live. EVIDENCE: The accommodation provided is of a high standard and all the bedrooms are of single occupancy. There is a range of communal sitting rooms and a dining room. There is a Chapel and rooms where the Sisters can go for private prayer and reflection. A wide range of equipment is provided to assist with mobility including overhead hoists and assisted bathing facilities. There are two passenger lifts and there is level access inside the home and to the garden. The garden is well tended and there are pathways around the garden to enable the Sisters to enjoy the garden safely. The Sisters decide how they wish to arrange their rooms to suit their tastes and to accommodate their hobbies and interests. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30. The Sisters receive a high standard of care from a motivated and well-trained staff group. EVIDENCE: The home employs qualified nursing staff, care staff, domestic and catering staff in sufficient numbers to meet the needs of the Sisters. The qualified nursing staff have the relevant general nursing qualification and attend regular training courses to up date their practice. All staff have a training portfolio and training achieved includes NVQ Levels 2, 3 and 4. Palliative Care, Dementia Care, Counselling, Medication, NVQ Assessor Certificate and Risk Assessment. There are link nurses who have special responsibilities for keeping up to date and staff training in wound care, infection control and moving and handling. There is a staff supervision policy in place and an annual appraisal system. The home has the required numbers of staff on duty during the day and overnight. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 38. The Sisters benefit from a well managed home where their needs and wishes are put first. EVIDENCE: The registered manager is a qualified first level nurse and has completed the Registered Managers Award. She has managed the home for a number of years and continues to update her practice and skills through training. Meetings take place on a regular basis enabling the staff and the Sisters to voice their opinions about all aspects of the service provided and to contribute to any future changes. The home is run in the interests of the Sisters to make sure that they receive the care they need and to live out their religious commitment. The required records policies and procedures were in place and found to be in good order and up to date and available to the staff. The home has a health and safety policy and procedure and staff are subject to health and safety training. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 15 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 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X 3 3 3 X 3 X X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 16 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. 1 Standard OP9 Regulation 13(2) Requirement The registered person is required to keep accurate medication administration records. Timescale for action 30/01/06 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 OP18 Good Practice Recommendations It is recommended that a copy of the local authorities procedure for the protection of vulnerable adults be obtained and that staff become familiar with the reporting procedure as detailed in the policy. Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Convent Society Of The Holy Child Jesus The DS0000027928.V265129.R01.S.doc Version 5.1 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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