CARE HOMES FOR OLDER PEOPLE
Cross And Passion Convent 19 East Beach Lytham Lancashire FY8 5EU Lead Inspector
Ms Janet Spink Unannounced Inspection 27th October 2005 12.30p 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.V250549.R01.S.doc Version 5.0 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.V250549.R01.S.doc Version 5.0 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 Sisters Of The Cross & Passion Josephine Donnelly also known as Sister Catherine Labouré CP Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To register one additional bedroom to increase the numbers occupied from 9 to 10 rooms (OP with nursing care provided). The bedroom is of the same specification as the other rooms in the home, has an en suite shower and toilet and is furnished to the same high standards 9th June 2005 Date of last inspection Brief Description of the Service: The Sisters of Cross and Passion Care Home offers residential and nursing care to ten patients who are sixty-five and older. Most of the patients belong to the same religious order. It is situated on the front at Lytham overlooking the green and sea. It is in close proximity of the local shops, the library and public transport. 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. The home provides a car park at the rear of the building. The nursing home is situated within a convent in a large detached Victorian building. It is staffed with Sisters of Province and additional care and qualified nurses from the wider community. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted over two and a half hours. It was the second inspection to this home this year. The inspector spoke to four patients, three staff members and the matron. A tour of the nursing home was undertaken and documents were read. There were seven patients accommodated in the home at the time of the inspection. What the service does well: What has improved since the last inspection?
The pre admission procedures have improved by developing a more formal assessment tool. This means that the home is aware of a person’s needs prior to them moving in. Procedures have improved when employing staff as all clearances including a police check is now done by the home. The matron has now completed the Registered Manager’s Award. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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 Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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): 3 There has been improvement in the pre-admission assessment procedures ensuring that the home meets the needs of the patients that are admitted. EVIDENCE: The inspector viewed the new assessment tool that has been developed by the matron. This addresses all care needs in a more formal manner than previously. Needs including mobility, communication, diet, medication and social interests are all included so that the staff have a clear picture of a person prior to admission. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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 Medication practices are within a safe framework ensuring patients are protected by procedures. EVIDENCE: The inspector looked at the medication practices in relation to one resident in the home. The storage of medication is in a locked cupboard, and controlled drugs are stored separately although nobody was in receipt of controlled medication at the time of the inspection. Records were found to be up to date and accurate. A system is in place to check all medication when it is received from the chemist. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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): 12 Social and recreational activities continue to be provided so that patients are stimulated. EVIDENCE: The inspector spoke to four patients who confirmed that social activities are provided in the home. All bedrooms have a TV and some have music systems as well. Books, newspapers and CDs are also available. Entertainment such as Beetle drives, quizzes and bingo are provided by a co-ordinator. The inspector saw an activities plan displayed for the sisters information of events coming up during December. This included mince pie making, Take Your Pick and a Stars in Their Eyes evening to be performed by the staff. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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 The home ensures that residents are aware of their rights and has a complaints procedure. Systems are in place to reduce the risk of abuse. EVIDENCE: The home has a complaints procedure in place, however there have been no complaints received. The matron and staff have created an open and homely atmosphere where patients are encouraged to voice their opinions on a daily basis, therefore ensuring any concerns are dealt with before they become formal complaints. One patient told the inspector “we are totally pampered here and have no reason to complain about anything.” Training on the awareness of abuse has been addressed by staff members through NVQ (National Vocational Qualification) level II in care. In addition, the matron has arranged for the national Midwifery Council to send their guidance on protection of abuse to each member of staff. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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): These standards were not assessed on this occasion. EVIDENCE: Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 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, 29 and 30. Staffing levels were high and were therefore meeting the needs of the sisters. Improvement in the recruitment procedures means that patients are safeguarded, and staff training continues to provided to ensure they are up to date with current good practice. EVIDENCE: The inspection was unannounced. There were seven sisters being cared for by the matron, two qualified staff and three carers. In addition to this there were two contract cleaners and a chef on site. The needs of the patients were therefore being met and staff were able to spend time with them. The inspector was told that “the staff make this place, they are wonderful.” During the last inspection the matron was advised to make recruitment procedures more robust by carrying out Criminal Record Bureau clearance for staff prior to them being appointed. There was evidence from discussion with staff and documentation that this is now being undertaken as POVA checks are being obtained routinely. Six of the eight care staff have achieved NVQ level II or III and therefore the home has reached its target of having 50 of the team qualified. One of the qualified staff is currently undertaking the assessors award. Other training continues to be provided such as moving and handling and infection control. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 14 The matron is aware of the new Skills for Care Council induction standards that are to be introduced in 2006. She is adapting the present system to ensure the home’s induction is in line with these standards. Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 15 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 The home is well managed and run in the best interests of the patients. There is good leadership, guidance and direction to ensure that patients receive consistent care. EVIDENCE: The matron has ten years experience of managing this home, and does so in a professional and caring manner. It was apparent that both patients and staff have great deal of respect for her and are confident in her abilities to manage. The matron has recently successfully completed the Registered Manager’s Award and the home had a party to celebrate this achievement. She works hard to ensure she meets any recommendations or requirements and is professional in her conduct with the Commission for Social Care Inspection.
Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 16 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 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 4 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x x Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 17 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cross And Passion Convent DS0000006082.V250549.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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