Inspection on 03/04/07 for Convent Society Of The Holy Child Jesus The

This inspection was carried out on 3rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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... 10/01/06

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 Denise Rouse Key Unannounced Inspection 3rd April 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 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 880453 01423 880292 infirmary@btconnect.com 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 Vacant post 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.V334991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 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. There is a Statement of Purpose available so that the Sisters have relevant information about the service. No fees are charged to the Sisters of the Order. The inspection report was available to all service users. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the homes file since its last inspection. • Information submitted by the registered provider in the pre inspection questionnaire. • Surveys received from six service users, one relative, and one health care professional. • An unannounced visit to the home, which lasted five and a half hours. This included a full tour of the premises. • Evidence gained by direct observation, talking with service users, management and staff. Inspection of records, including care profiles, medication administration records, staff files and the homes policies and procedures. What the service does well: What has improved since the last inspection? Medication systems have been improved to ensure the service users receive their medication safely. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 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.V334991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (6 Not applicable) People who use this service experience excellent quality outcomes in this area. Service users were assessed to ensure their needs could be fully met, prior to being offered a permanent placement at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All service users were involved in a pre admission assessment. The home manager went out to see service users before they were admitted, even if this was away from the local area. This ensured that the sister’s needs were known and that their assessed needs would be met. All the sisters were aware of the homes existence, and knew that this facility was open to them when they need it. Some service users came for respite care and following this they knew that the home could meet their needs and chose to reside at the home on a permanent basis. This ensured that the sisters had already built up relationships with the staff and were fully aware of the Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 9 services and facilities available to them. The care home had been provided purely to provide for the sisters of The Order and had been designed to ensure that all aspects of the sister’s care and religious life were fully provided. Staffing levels were provided to ensure that staff had quality time to spend with new service user; this helped them to settle within the home. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 8 9 10 People who use this service experience excellent quality outcomes in this area. Service users were treated with dignity and respect, their health and personal care needs were well met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Two service users plans were inspected, they were detailed including risk of falls, mobility, continence and psychological mental assessments. The documentation was reviewed each month with the service user and their key worker. Those capable signed the review documentation. A service user stated, “ I have found my health needs to be quickly identified and appropriate action taken”. This ensured that the service users needs were met. Risk assessments were in place to ensure the sisters remained safe whilst fully asserting their independence and living as full a life as physically possible. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 11 Staff were respectful to service users and addressed them by their preferred name. All service users were seen to be treated with dignity and respect. A service user stated, “ Clients are addressed in the manner they choose, Doors are knocked on and answers waited for before staff enter”. Service users could follow their own chosen routines of daily living, which were individual and very varied. The service users controlled their lives and directed the staff to provide the support they required. Service users confirmed that they could see the general practitioner of their choice. Hospital and opticians appointments could be attended, staff were available to escort service users as necessary. One sister stated “ It drives me mad, there’s always GP appointments etc to keep me well ”. Another comment received was “ Staff use the skills and experience of specific health care professionals involved to support clients as required, when they do not have those skills themselves”. This ensures that service users needs are fully met. Medications were inspected for the case tracked service users, all medications received were recorded, all returns documented. A controlled drugs balance was checked and found to be correct. There was a dedicated nurse for ordering medication and the home had purchased a safety system for safe storage of medication waste. This ensured the medication systems in operation were protecting the service users and staff. Comments received included “Always the staff of the care home take a personal interest in each of the residents, and their personal, individual needs are met to a very high degree”. And “ Staff do all they can to meet the different needs of the sisters, including making it possible for them to continue to live their lives as members of a religious order to the best of their ability in their old age & infirmity”. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 14 15 People who use this service experience excellent quality outcomes in this area. Service users followed their chosen routines which were full and varied, and had lots of activities available to them; they also received a well-presented nutritious diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There was a daily Holy Communion held within the convent. Easter celebrations were being planned. And Christmas service and events were all held. The staff would bring in their families to join the sisters in celebrating these religious festivals so that the sisters felt “ they were all one happy family”. Service users within the home stated they were all very happy with the activities available to them, and that they met their preferred social needs. There was a formal weekly schedule of activities displayed but there were also ad hock activities and outings taking place. The afternoon of the site visit card making occurred in the conservatory. The sisters spoke of their enjoyment at this craft and were pleased to show the inspector the range of materials they Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 13 had used as well as the cards they had made. The sisters were able to go into Harrogate shopping accompanied or unaccompanied. One stated I get dropped off on Ripon road, and go to the Edinburgh Wool shop and then for a coffee, sometimes to Betty’s”. There were beautiful gardens and rose beds with garden furniture so that the sisters could enjoy the grounds. Another stated, “ I can read and watch television, I am a very political animal and I vote at local elections”. It was observed that the sisters liked to live their lives and fit as much as possible into their daily routines; one stated that they tried to achieve so much in one day that sometimes the staff had to remind them to rest. There are always a variety of events to take part in. A hairdresser also attended the home on a weekly basis. Service users could receive visitors whenever they wished. The grounds also contained a sheep, chickens and a wild pheasant, which were attended to by the sisters. There were two cats living at the home, as pets. This ensured that links with wildlife were maintained. There were a number of lounges and quiet areas for prayer and reflection. The care home was attached to the working convent and this allowed the sisters access to the chapel and other areas of the convent at their will, to fulfil their religious commitments and preferences. Daily newspapers and a well-stocked library were available to the sisters. There were a number of televisions and videos available, in varying lounge areas throughout the home. The kitchen was inspected, it was clean and tidy. The food served for lunch was seen to be nutritious and appetizing, service users stated, “ The food is good”. Service users could have whatever sized portion they wished. The chef knew the needs of the service users. Meals were unhurried and staff assisted service users with great dignity and respect. Staff ate with the sisters at lunchtime; this gave a family feeling to mealtimes. Comments received included “ We have wonderful meals here, full marks for meals”. “Our chef makes sure that my diet is suitable for me”. And “ The care home staff provides a relaxed, homely atmosphere in which the sisters can feel safe & cared for while still living as part of a religious community. They give whatever time it takes to listen to and help each one to go beyond the call of duty to take them out, do shopping for them etc, they are also very welcoming to visitors”. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 18 People who use this service experience excellent quality outcomes in this area. Service users are protected from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There had been no complaints received since the last inspection. There were policies and procedures in place, which were available to the sisters, and staff to ensure that any complaint received would be dealt with quickly and in a thorough manner. The manager and staff constantly asked for informal feed back from the sisters to ensure that there were no complaints. This ensured that service users concerns, if any were dealt with promptly. All relevant staff received training in these areas at induction and during their employment. Staff were aware what action they should take if they ever received an allegation of abuse. A copy of “ No secrets” was available. However a copy of the local authorities policy and procedure also needs to be available for staff to refer to. The new manager phoned to gain a copy of this. Further videos for staff training were to be obtained, to ensure that the sisters continued to be protected by staff who were well educated in relation to adult protection. All staff had completed the relevant pre employment checks to ensure that they were suitable to work within the care industry. These were undertaken Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 15 before staff commenced at the home and ensured that the recruitment process operating within the home protected the service users. The deputy manager had created a new auditing system whereby each sister was to be asked on a monthly basis if they had any concerns or complaints. This system was also to be used to ensure there were no adult protection issues. This ensured that the sisters were constantly protected by the homes systems in place. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 26 People who use this service experience good quality outcomes in this area. Service users lived in a homely clean environment, which was very well maintained, however the laundry required a spring clean. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All areas of the home were comfortable, well maintained and clean. Most areas were decorated to a high standard, some areas were a little dated in décor but had a wonderful relaxing homely feel. The quality of furniture and fittings was also good and in keeping with the house and the age and needs of service users. Most areas were spotlessly clean apart from the laundry drying room, which required a spring clean due to build up of dust. This was to be cleaned immediately. There had also been some damp within one corner of this room; Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 17 this was to be discussed with the contractors who had built this room. To ensure that staff and service users health and safety was maintained. All bedrooms were for single occupancy, and were personalized with the sisters chosen possessions. Some were en suite; there were sufficient communal bathrooms and toilets. There were a number of lounges and a dining room and the large grounds were accessible to both mobile and wheelchair service users, they were well maintained and service users stated “they are beautiful in the summer and contained lots of wildlife”. There are plans to develop and improve the facilities on the site, which will enhance the home and ensure that it will be able to accommodate all the sisters who wish to reside within this community at a later date. Hand washing facilities and alcohol solutions were available through out the home for nursing and care staff to utilize. There was even a hand rub solution that visitors could use when entering or leaving the building. These measures ensured that infection control was in place to protect staff, service users and visitors. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 28 29 30 People who use this service experience good quality outcomes in this area. Service users are looked after by high levels of well-trained staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Service users confirmed that they were very happy with the staffing levels, which were maintained at a high level ensuring care was given timely and to a high standard. All necessary pre employment checks had been carried out to ensure the staff employed were suitable to work within a care home. Staff had completed Fire training, however training in moving and handling was slightly overdue, however there were dates for all the staff to attend this training advertised. The manager stated that the home have a good training budget which permits the staff access to a lot of courses, which enhance the care service users receive. The views of the staff team were sought by holding regular staff meetings. Staff undertook appraisals, these had just commenced. Some staff supervision had occurred however this was not up to date for all staff. The manager and deputy were aware of this and were dealing with this to ensure that Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 19 supervisions would be scheduled and undertaken promptly. To ensure that any training needs identified during this process would be provided. Comments received included “We work together to support the residents”. And “Care staff always have the right skills needed. We have some very experienced nurses and carers. They up date themselves with courses and training undertaken in house and elsewhere”. Also “ I have found the staff at the convent to be caring and empowering towards their clients. There are enough staff to ensure individuals needs are proactively identified and met, the staff work closely with our team to support clients” “ I have not identified any ways that the service could improve to help my clients”. Staff spoken with stated they felt privileged and lucky to be working in such a fantastic home. They also stated that they all saw the sisters and themselves as part of a large happy family. This came across during the site visit and was a pleasure to witness. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 33 35 38 People who use this service experience good quality outcomes in this area. Service users live in a home that is well managed, quality assurance systems were in place, however these could be more formalized. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff stated that the new manager was supportive and approachable. She was looking at how to improve the services provided within the home, and how she could be available to all the service users and staff. The manager was going to undertake a night visit, to ensure the quality of the service was equally as good over a twenty- four-hour period. A comment received stated, “ The home is well managed and there is a happy, caring atmosphere in which the sisters can live the last years of their life”. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 21 Quality assurance systems were in place, and being further developed, the heads of departments, nursing staff and manager were constantly assessing and re evaluating the services provided to the sisters. It was suggested that they might wish to document these audits and assessments being undertaken, to add to their quality assurance evidence. A weekly meeting held with management and all heads of department was held to ensure all parties were fully informed of any issues and to discuss issues relating to the week ahead. Staff and service user meetings were held regularly to ensure that any issues raised would be dealt with. Health and safety records were inspected, these were found to be correct. This ensured that all relevant maintenance was being undertaken to protect the service users and staff’s health and safety. The manager also attends a two monthly meeting of the Advisory Board, presenting a report about the care home and services and allowing the Board to give advice as required. The deputy manager was just commencing a further audit, asking each sister individually, about her views of the services provided within the home. This was to be undertaken monthly. This ensures that the service was always being monitored for good quality and any issues would be rectified quickly. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 2 STAFFING Standard No Score 27 4 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 23 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 OP30 Regulation 18 (2) Requirement Staff supervision must be undertaken and recorded for all staff on a regular basis. Timescale for action 10/05/07 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 2 3 Refer to Standard OP18 OP26 OP33 Good Practice Recommendations A copy of the local authorities procedure for the protection of vulnerable adults should be obtained. The laundry drying room should be thoroughly dusted. Staff should record all auditing of the service, which is taking place. Convent Society Of The Holy Child Jesus The DS0000027928.V334991.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V334991.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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