Inspection on 14/05/07 for Cross And Passion Convent

This inspection was carried out on 14th May 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

Cross And Passion Convent 27/10/05

Cross And Passion Convent 09/06/05

Cross And Passion Convent 24/08/04

Cross And Passion Convent 06/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Cross And Passion Convent 19 East Beach Lytham Lancashire FY8 5EU Lead Inspector Denise Upton Unannounced Inspection 14th May 2007 09:10 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 Cross And Passion Convent DS0000006082.V335435.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. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cross And Passion Convent Address 19 East Beach Lytham Lancashire FY8 5EU 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) 01253 736913 01253 732623 susandonegan@btconnect.com Sisters Of The Cross & Passion Josephine Donnelly also known as Sister Catherine Labouré CP Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: The Sisters of Cross and Passion Care Home offers residential and nursing care for up to sixteen patients who are sixty-five and older. Most of the patients belong to the same religious order. The home is situated on the front at Lytham overlooking the green and is in close proximity to the local shops, library and public transport network. Accommodation is provided in single bedrooms all of which have adapted shower en-suite facilities. There is one assisted bathroom, a lounge and large dining room. An additional seating area is also provided in the reception area of the home. The nursing home is situated within a convent in a large detached Victorian building. The Cross and Passion Convent is staffed with trained nurses and care assistants from the local area, the Matron of the home is from the Sisters of the Cross and Passion. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a midweek day and in total spanned a period of just over eight hours. At this inspection, all of the key national minimum standards were assessed. There were eleven Sisters living at the home at the time of the visit. Discussion took place with the registered manager, deputy matron, chef, a qualified nurse and a care assistant. In addition, individual discussion took place with two people living at the home. These people gave a good overview of their experiences of living at the Cross and Passion Convent. Time was also spent briefly meeting other residents mainly in communal areas of the home. A number of records were examined and a partial tour of the building took place. Prior to the inspection, seven people living at the home completed the Commission For Social Care Inspection comment cards. Comment cards were also received from eleven relatives/carers. This provided further information on how people using the service and their relatives/carers felt that the Cross and Passion Convent was meeting the needs and requirements of people who lived there. All comments made were extremely positive. Information was also gained from a pre inspection questionnaire completed by the registered manager. The total key inspection process focused on the outcomes for people living at the home and involved gathering information about the service from a wide range of sources over a period of time. The current scale of charges is £400:00 per week. What the service does well: The Cross and Passion Convent care home has a group of staff that work well together and are very much liked by people who live at the home. The Matron is well qualified, very experienced in running the care home and has good leadership skills. A high standard of care and support is provided and staffing levels are generous. This means that the staff team have opportunity to spend time with people living at the home and organise activities. One person commented that the staff are, “very caring they are always around” and that staff are “most obliging and attentive”. It is very clear that good relationships exist between people living at the home and the staff group, which helps people feel comfortable and secure. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 6 A volunteer at the home also pointed out how good the staff team was in enabling people to live the life of their choice saying that, “The primary and overall needs of the residents (i.e. faith needs) are met at all times since they are members of the same religious order which runs the home. Their individual needs are also carefully considered and met” The standard of the environment at the Cross and Passion Convent care home is very high, providing people who use the service with a welcoming, attractive and comfortable place to live. People were also very complementary about the quality and variety of meals served. What has improved since the last inspection? What they could do better: The Cross and Passion Convent care home is a very well managed home and all staff work hard to ensure that high standards are maintained and that the nationally recognised requirements and recommendations in respect of care homes for older people are in place. However there are a small number of things that could be improved. There is a requirement that a senior person from the Religious Order should visit the care home on at least a monthly basis and produce a written report. At present visits are taking place less frequently than once a month and should be increased. Although staff are informally supervised on a day-to-day basis, regular formal one to one staff supervision should be introduced with a written record kept. Consideration could also be given to ensuring that the staff team are aware of the local arrangements in place should an allegation of abuse be made. This would help to ensure that staff did not inadvertently respond inappropriately. All qualified and care staff that have not done so should be provided with updated first aid training. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 7 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. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 8 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 Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 was not assessed as the Cross and Passion Convent is not registered to provide an intermediate care service. Quality in this outcome area is good. The pre admission assessment to identify what the prospective resident can do well and what help may be required is detailed in order to establish if current needs, wants and wishes could be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As it is normally only The Sisters from the Cross and Passion that are admitted to the Cross and Passion Convent, the matron of the home already has a good understanding of their individual needs and requirements as she has known any new prospective sister for many years. Although the majority of sisters living at the home had previously been resident in another care home managed by the Sisters of the Cross and Passion, each sister has a free choice to select an alternative care home with nursing if this becomes necessary. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 10 However in reality, the vast majority of sister’s choose to remain within the Order and are therefore admitted to the Cross and Passion Convent. Never the less there was still clear evidence that a full and comprehensive, formal pre admission assessment process had been undertaken to ensure the Cross and Passion Convent could provide the level of care and support required. It is routine that any new prospective sister is visited in her current environment in order to conduct an initial assessment of current strengths and needs This pre admission assessment carried out by the Matron is further supplemented by information made available from the manager of the current care home and in some instances provided through other professional assessments such as hospital discharge information. This combined information is then collated and provides a basis for the initial care plan. On admission each sister is provided with a copy of the recently amended Service User Guide that is left in the individual bedroom accommodation. Members of staff spoken with were clearly very aware of the individual needs and requirements of each Sister and confirmed that they were able to access the care plans, policies and procedures, which showed that they were able to obtain relevant written information if and when they needed it. One of the written comments made by a visitor to the home emphasised the importance for most Sisters of remaining within their religious community stating that “This particular setting ensures that the Sisters are able to continue living their lives as members of a religious community, with special attention being given to their increasing medical and nursing needs.” Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is excellent. There is a clear and consistent care planning system in place that gives specific guidance to staff in order for them to satisfactorily meet the individual Sister’s needs and requirements. The health care needs of the Sister’s are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication in this home is well managed promoting good health. Personal support is provided in such a way as to promote and protect the Sister’s privacy, dignity and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 12 All people living at the Cross and Passion Convent Care Home have an individual plan of care based on current assessed strengths and needs that is developed from the initial assessment process. There is a consistent approach to the care planning and review system. Care plans observed were found to be comprehensive, detailed and clearly informed staff of how an objective was to be achieved in order to ensure consistency of care and support for the individual. There was evidence of relevant risk assessments having been undertaken with significant outcomes incorporated in the care plan. All care plans are formally reviewed on a monthly basis. Two Sisters individually spoken with clearly thought that their needs and requirements were being met very well by staff at the home and had nothing but praise for the care and support received. One Sister stated that “Matron sees what’s wrong with you before you know yourself, attention is given immediately. She is strict but loving and caring at the same time” Another Sister had asked a care assistant to write on the Commission for Social Care Inspection survey form that she was “very pleased with the care and support especially the giving of Holy Communion in her room if she feels unable to go to Chapel”. The Sisters spoken with felt their privacy and dignity was respected and that staff were sensitive when they needed help with personal care. Staff had an overall understanding of the needs of people who lived at the home and were seen to be patient, kind and respectful when interacting with residents. A relative wrote that staff, “Always treat my mother with respect and dignity. The service is far better than we could have hoped for” Through discussion with residents and staff and observation of documentation, there was clear evidence of good multi disciplinary working with health care professionals. It was noted that a General Practitioner (G.P.) visits on a weekly basis and any visit by a health care professional is recorded. People spoken with felt that their health care needs had been fully met whilst they had been living at the home. Comments on the Commission for Social Care Inspection (CSCI) resident survey forms, also confirmed that people who live at the home felt that they always received the medical support they needed. The home has good systems in place for the administration and recording of medication. Medication administration records observed were accurate and well maintained. Medication administered by staff, is stored in a locked cupboard and medicine trolley that is secured to the wall in a dedicated medication room that is also kept locked when not in use. Only qualified nurses have designated Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 13 responsibility for medication administration and are expected to adhere to the home’s policy and procedures for the receipt, recording, storage, handling, administration and disposal of medication to ensure the safe administration and recording of medication. Appropriate controlled drug storage is available although nobody was in receipt of controlled drug medication at the time of the visit. The Cross and Passion Convent care home was found to be meeting the personal and health care needs of people living at the home in an excellent manner. This was also reinforced by a comment made on a CSCI survey form completed by a volunteer to the home who stated, “ I feel that a special understanding on the part of the care staff is needed here, so the idea of having the ‘right skills and experience to look after people properly’ does not cover the whole requirement. I do not know all members of the care staff, but I can say I do know that they bring a great deal of compassion, sympathy and patience to their work as well as a wise understanding of the position of the increasingly frail religious sisters”. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent Residents experience the lifestyle that satisfies their social, cultural, religious and recreational interests and needs. People who live at the home are encouraged to maintain contact with the local community and their family and friends to ensure these relationships are sustained. Dietary needs of people who live at the home are well catered for with a balanced and varied selection of food available that meets individual taste and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Routines of daily living and social activities are kept flexible and varied in order to address individually assessed strengths and needs. A number of residents access community resources and facilities either independently or enjoy the one to one support of staff for outings and activities. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 15 Visitors are made very welcome including parishioners from the local community who regularly visit to attend Mass and to talk with the Sisters. A variety of social activities are made available including film shows, card making, bingo, outside entertainment, visits out in the local community and beetle drives. A ‘memory box’ is in the process of being established to initiate discussion and help recall memories. In addition the Sisters frequently find a reason for enjoying a good party that includes birthdays and religious festivals. Although organised social activities do not take place on a daily basis, the Sisters spoken with felt that plenty of activities were provided to suit their needs and requirements and did not feel the need for any more. It was noted that books, newspapers and CD’s are also available for any Sister who wishes be entertained in this way. Written comments from staff confirmed that the key workers also assist individual residents to write letters to family and help people living at the home to make phone calls to enable “our ladies to keep in touch with family” Religious and spiritual needs are given careful consideration. The convent Chapel is in the same building and one carer commented “They (the Sisters) can attend the services in the Chapel within the convent every day or go to St Peters Church. It is their choice, as the options they have to lead their lives”. One Sister spoken with explained how she liked the ‘order’ of living at the Cross and Passion convent and how her whole life had been ‘ordered’. Living at the home enabled her to continue with the order of her religious life that clearly was very important and provided much valued continuity. Through discussion and observation of some bedroom accommodation it was clearly evident that individual bedroom accommodation is personalised to suit the occupant and provided with personal possessions to make individual space more homely and comfortable. Meals and mealtimes at the home are given high priority with a varied and balanced menu provided that is designed round the known likes and dislikes of people living at the home. Specialist diets in respect of medical needs are provided and as observed, hot and cold drinks and snacks are made available throughout the day. The Sisters individually spoken with were both very positive regarding the quality and variety of the meals served. Breakfast is served individually to residents in their bedroom at a time convenient to themselves with main meals served in the dining room unless the person is unwell or chooses to eat in an alternative place. Brief observation of the lunchtime meal confirmed that fresh produce was served that was attractively presented, well cooked and placed in serving dishes to enable the Sisters to help themselves at the table. It was Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 16 also noted that staff discretely and sensitively offered assistance when required to ensure the dignity of Sisters requiring assistance was maintained. Although the lunchtime meal is generally a set main meal with a choice of puddings, there is always an alternative of choice made available. There is a wide choice of foods at the evening meal and staff sit and eat with the Sisters at this time. Designated catering and domestic staff are employed from a separate organisation. The chef explained that when a new resident is admitted to the home, it is usual practice for the unit manager to personally speak with the person and find out what their dietary requirements, likes and dislikes are. Menus are regularly reviewed. The catering team regularly win prizes in annual national cooking competitions and take a great pride in their catering achievements. The chef confirmed that a very adequate budget is available for the provision for foods and went on to say that, I love working here, I feel very well supported”. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system with evidence that people who live there feel their views are listened to and acted upon. Staff have received training in respect of adult protection issues that helps protect residents from potential abuse. However staff could receive further training to help ensure that inappropriate action is not inadvertently taken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, no complaint or adult abuse allegation has been made in respect of the home. The complaint procedure at the Cross and Passion Convent care home is made available to new residents in the written information they receive at the time of their admission. Sisters individually spoken with said they were aware of the complaints procedure but had never had cause to make a complaint. This was also confirmed by the written comments made on the CSCI survey forms with one resident stating in response to the question; “do you know how to make a complaint’ wrote “yes, but I never need too”. The Matron and staff create an open and homely environment where people are encouraged to voice their views and opinions on a daily basis, therefore Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 18 ensuring that any concerns are dealt with immediately before they become formal complaints. Training on the issues of awareness with regard to adult abuse is addressed through National Vocational Qualification (NVQ) training Level 2 & 3 in care. Although staff spoken with were aware of adult abuse issues and what they would do if an allegation of abuse was made to them, they were less familiar with the protocols of investigating an allegation of abuse as indicated in the ‘No Secrets In Lancashire’ multi agency document. Consideration could be given to ensuring staff become more familiar with the protocol in this document to ensure they do not inadvertently take inappropriate action. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. The standard of the environment within this home is excellent providing people who live there with a safe, attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the Cross and Passion Convent care home are accommodated in ground floor accommodation that is well-maintained, domestic in character and has been designed to meet individual and collective needs. The layout of the home provides residents with opportunity to move freely round the building and access all areas with ease. Communal areas consist of a comfortably furnished community room, large dining room, reception area with seating, an adapted bathroom and a newly created refreshment room where individuals, including visitors and staff, can make drinks and snacks. All individual bedrooms are spacious and provided with an adapted en-suite Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 20 facility. Accommodation is also made available for family members when visiting if required. Since the last inspection additional en-suite bedroom accommodation has been provided that is in keeping with the rest of the home. Bedroom accommodation is very comfortable, individually decorated and furnished. Appropriate aids including hoists and air mattresses are provided as required and currently all beds are in the process of being replaced. It was noted that by some bedroom doors, the name of the occupant was displayed in large print to enable individuals with impaired vision to read the information more clearly. People who live at the home have access to a large private well-maintained garden area that is provided with seating areas and smaller garden areas in various locations. This means that each communal room and all private bedroom accommodation in the home look out onto a garden area. Facilities and equipment in respect of laundry services at the Cross and Passion Convent are compliant with the recommendations. The Home has policies and procedures for the control of infection and safe handling of clinical waste. Laundry services are appropriately sited away from kitchen and dining areas and do not intrude on people who live at the home. Hand washing facilities are available in laundry areas and washing machines comply with disinfectant standards. Sluice facilities are provided. At the time of the visit it was observed that the home was very clean and well maintained and free from offensive odours. The Home maintains an on-going maintenance and renewal programme with records kept. The Cross and Passion Convent care home complies with the requirements of the Environmental Health Department and Fire Service. Fire alarm tests are conducted weekly and fire drills are conducted on regular basis. The Sister’s spoken with were very satisfied with the standard of accommodation and the cleanliness of the home. Various written comments made on this subject in response to the question, ‘is the home always fresh and clean’ included, “perfect and high standard of hygiene” and “the housekeepers work very hard and keep the home very fresh and clean” and “always spotless”. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is excellent. There is a good mix of staff offering consistency of care within the home. The arrangements for the induction and more advanced National Vocational Qualification (NVQ) training in care are good with staff demonstrating a clear understanding of their roles. There is a structured and robust process for the recruitment of staff that includes obtaining satisfactory references and clearances in order to protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels at the Cross and Passion Convent care home are generous and determined in order to make sure that people living at the home are well cared for and well supported. Since the last inspection there has been a number of staff departures and staff appointments resulting in the need to provide some agency staff for periods of time. This has been managed by ensuring that only a small number of the same agency staff work at the home who get to know the people living there and the regular routines of the home in order to provide consistency and familiar faces. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 22 People spoken with that live at the home were all very pleased with the staff group and the kindness of the staff. One person wrote that “I am very happy here, everyone is so kind and attentive”. Another person said, “ I am very happy with everything that is done for me”. A member of staff also commented that, “I feel proud to work at Cross and Passion Convent with the high standards that the staff give daily in all aspects of care”. The skill mix of staff includes qualified nursing staff and care assistants. Staff training is encouraged and it is understood that all newly appointed care staff that have not done so, undertake the ‘Skills for Care’ induction training programme. National Vocational Qualification (NVQ) training in care is also positively encouraged. Currently eight out of the ten care assistants have achieved an NVQ qualification. The remaining members of the care assistant team are working towards completing this course of study. Records of individual staff training were evidenced that highlighted the additional range of courses that certain members of staff had undertaken in order to provide a high quality service. This included training in respect of palliative care, last days of life, incontinence, food hygiene, key lifter, basic nutrition, and fire training and risk assessment. The Cross and Passion Convent Care Home has in place a structured recruitment policy and procedure that helps to protect people who live at the home. Since the last inspection, new members of staff have been appointed. From observation of two recently appointed staff member’s personnel file, it was evident that the recruitment policy and procedures had been followed. This included an application form, formal interview, references and a Criminal Records Bureau (CRB) POVA clearance had been obtained prior to the applicant actually taking up post at the home. A member of staff spoken with confirmed that when she began working at the home she was closely mentored for a period of two weeks. This was to make sure that her work was of a good standard and that she understood the values and philosophy of the home. It is understood that during this period, the new member of staff is supernumerary to staffing requirements. If the new member of staff is appointed for night duty, they are mentored for the first week on day duty followed by two weeks on night duty. After the period of mentoring, a formal discussion takes place with the recently recruited member of staff to clarify if the person is suitable and to ensure that the new member of staff is satisfied with working at the home. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate. The manager is qualified, experienced and supported by the senior staff in providing clear leadership throughout the home. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of people living at the home. However a senior representative of the Order must visit the home on at least a monthly basis and produce a written report on the conduct of the care home. Systems are in place to ensure as far as possible the health and safety of service users, staff and visitors. Formal one to one staff supervision should be introduced that is recorded. This would provide opportunity for individual discussion including practice issues, career development needs and the values of the home. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 24 This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Matron/Registered Manager at the Cross and Passion Convent is very experienced, well qualified and supported by senior staff in providing a high standard of care. The Registered Manager is a qualified nurse who has also completed the Registered Managers Award, therefore increasing her knowledge and skills and extending her personal development. In addition, the Registered Manager has undertaken a variety of other training and is the link nurse for palliative care at the Hospice. This involves providing advice and information. The home is managed in a professional and caring manner. It was apparent that people living at the home and the staff group have a great deal of respect for the registered manager and in the way she manages the home and supports and values people. A member of staff stated, “This is a well run and caring Convent”. A relative commented that, “It (the care home) cannot improve. How do you improve on ‘excellence’. Although the Matron/Registered Manager manages the home very well, there is a requirement that a senior representative of the Order must visit the Cross and Passion Convent on at least a monthly basis and write a report on the conduct of the care home. Whilst visits by a senior representative of the Order are made on a regular basis, these visits are conducted less frequently than once a month. It is essential that a senior representative of the order visits the care home on at least a monthly basis and writes a written report. Quality monitoring and quality assurance systems are in place that suits current needs. People who live at the home are elderly and frail and in the main prefer informal day-to-day discussion rather than more formal ways to express their views and opinions. However there has recently been a questionnaire to complete regarding foods that the catering manager organised. Staff meetings do regularly take place as do group supervision, however group supervision is not necessarily recorded. Individual one to one staff supervision has yet to be introduced. A member of staff spoken with confirmed the arrangements in place and the process of verbal information sharing at shift handovers to ensure that all staff are aware of any changes. Whilst daily informal staff supervision as part of the management role is continuous, formal, recorded one to one staff supervision should be introduced. This would provide opportunity for individual pre planned discussion about the Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 25 values and practices of the home and provide a forum for establishing individual training needs. It is understood that an appraisal takes place on an annual basis. One member of staff spoken with self identified her own training needs and although she felt that any training requested would be provided, this had not been discussed. Formal one to one supervision would have provided an opportunity for this member of staff to express her wishes and to establish any other training that may be beneficial to enhance her skills and knowledge for the benefit of people living at the home. It is recommended that formal staff supervision takes place at least six times a year. The Sisters living at the Cross and Passion Convent all agreed to respect the financial arrangements of the religious order when they entered the Convent. This commitment is ongoing. Every need and requirement of the Sisters is fully met by the religious order. The Cross and Passion Convent ensures safe working practices are maintained through observing policies and procedures and staff training in respect of health and safety issues. All members of the staff team receive mandatory health and safety training covering a variety of topics appropriate to their role. Environmental risk assessments are in place. At present, updated first aid training is being arranged for all qualified staff and some care staff have received basic first aid training. However first aid training for all qualified and care staff is a requirement and those members of staff that have not done so should receive this training. Manual handling training is mandatory and infection control training is provided ‘in-house’ with input from the tissue viability nurse. Maintenance records were available to confirm that various routine health and safety checks are maintained on a regular basis to the internal and external environment of the home. It was also noted that equipment is regularly serviced. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 2 X 3 Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. ! Standard OP33 Regulation 26 Requirement A senior representative of the Order must visit the home on at least a monthly basis and produce a written report on the conduct of the care home. Timescale for action 31/08/07 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 OP36 OP38 Good Practice Recommendations Consideration could be given to ensuring that the staff team are aware of the ‘No Secrets In Lancashire’ protocols. It is recommended that formal, documented one to one staff supervision be introduced that takes place at least six times a year. Qualified staff and care assistants that have not done so should undertake first aid training. Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Cross And Passion Convent DS0000006082.V335435.R01.S.doc Version 5.2 Page 29 - 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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