Inspection on 09/06/05 for Cross And Passion Convent

This inspection was carried out on 9th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 14/05/07

Cross And Passion Convent 27/10/05

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 & Passion Nursing Home 19 East Beach Lytham Lancashire FY8 5EU Lead Inspector Janet Spink Announced 9 June 2005 9:00 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 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 & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cross & Passion Nursing Home Address 19 East Beach Lytham FY8 5EU Telephone number Fax number Email 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 Convent Josephine Donnelly also known as Sister Catherine Laboure CP CRHN Care Home with Nursing 10 Category(ies) of OP Old Age 10 registration, with number of places Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To register one additional bedroom to increase the numbers occuied from 9 to 10 rooms (OP with nursing care provided). The bedroom is on the same specification as the other rooms in the home, has an en-suite and toilet and is furnished to the same high levels. Date of last inspection 24 August 2004 Brief Description of the Service: The Sisters of Cross and passion Care Home offers residentisal 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 & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was conducted over five hours. The inspector spoke to five patients, three staff members, the matron and the secretary. A tour of the nursing home was undertaken and documents were read. There were no visitors present at the time of the inspection, but comment cards and a letter were received from relatives, who all made very positive remarks about the home. What the service does well: What has improved since the last inspection? What they could do better: The home’s recruitment processes could be improved to ensure that Criminal Record Bureau clearances are obtained for new staff, and that they are not accepted from a previous employer as these are no longer portable. The pre admission documentation would be improved if more details of personal needs are obtained prior to admitting a new person in to the home. Regular 1-1 supervisions with staff should be held and a written record should be kept. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 6 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 & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 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 standard(s) 3 The matron has excellent knowledge of the sisters needs as she has known them many years, however this needs to be formalised in to a written assessment to ensure the home admits people whose needs it can meet. EVIDENCE: The pre admission assessments were viewed for two patients. These were not detailed as the matron explained the sisters admitted are from the Sisters of Province Order and therefore she has known them for many years and feels she has sound understanding of their needs. She agreed to formalise the process in the future by using pre admission documentation that is already established in the home. This will ensure that the decision making process regarding admitting someone will address all personal, health and social needs of a patient. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 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 standard(s) 7,8,10 and 11 The home ensures that personal and health needs are continually monitored so that individual needs are met. Patients are treated respectfully and with dignity in all areas of their lives, and their wishes are respected in the event of their death. EVIDENCE: The inspector viewed care plans for two people who had high dependency needs. Both of the care plans are informative giving clear directions for staff in relation to bathing, moving and handling and level of personal assistance required. Daily notes were viewed and these confirmed that all appointments with GP’s and other health care professionals are recorded in detail. A comment card was received from the local GP who stated “a high standard of care is offered and consistently maintained.” The GP visits weekly as routine as well as attending when requested. Appropriate adaptations and aids are available for assisting with moving and handling, and the inspector noted that pressure relief mattresses are provided. There was nobody accommodated who had pressure sores. The home was found to be meeting the personal and health needs of the patients. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 10 The inspector was told that staff are respectful and meet personal needs in a dignified manner. All bedrooms have en-suite facilities, which one patient referred to as a “god send” as this maintained her privacy and dignity. There have been two deaths recently in the home, and this was dealt with in a manner appropriate to the sisters’ religious beliefs and wishes. Staff informed the inspector that the matron informs them on an individual basis even if they are off duty in the event of a death and commented that they felt “valued and respected” by this. All staff attend the funeral service if they wish, and are included in the whole process. A letter from a relative commented that “My aunt not only got professional care but also got constant attention and companionship and all ensured that she was never left alone as she passed peacefully away.” Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 11 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 standard(s) 12,13,14 and 15 The home ensures that social, cultural and spiritual needs are met, and that contact with family is maintained. The patients receive a high quality and varied diet, which ensures that they are receiving the correct nutrients for their well- being. EVIDENCE: The patients and staff told the inspector that activities such as bingo, beetle drives, outside entertainers and quizzes are provided in the home. In addition the sisters always find a reason to party – such as birthdays and religious festivals. It was noted that books, newspapers and CDs are also available for their use. There were no visitors present during the inspection, but comment cards were received relatives who confirmed that they can visit when they choose. Accommodation is available for those visitors who have travelled some distance. The inspector was present during lunch time where she observed fresh meat and vegetables being served. There was a choice of sweets which included fresh fruit. The meal was presented in serving dishes at the tables so patients could serve themselves. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 12 The inspector was informed that the qualified chef has built a rapport with the sisters and often visits the dining room to ask for their opinions of food being served. It is routine for the chef to visit a newly admitted person in their room to find out about their likes/dislikes and any special diets. People who needed assistance were seen to being helped in a sensitive and relaxed manner. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 13 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 standard(s) None of these standards were assessed on this occasion. EVIDENCE: Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25, and 26 The home provides a clean, comfortable and safe environment ensuring that patients live in well maintained and homely surroundings. EVIDENCE: The inspector was shown around the nursing quarters of the convent, and saw that all accommodation is single and have en-suite facilities. The en-suite have adapted showers, and there is also an adapted bathroom available for those who choose this. All bedrooms were seen to contain personal belongings such as CDs, photographs and books. They were seen to meet the needs of the person accommodated. They were light and airy and clean. There is a conservatory area and a large dining room for patients use. There is also a large, private and well- maintained garden that is used regularly. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 15 All documentation was viewed to confirm that testing and maintenance of services and equipment has been carried out and all is satisfactory, meaning that the home is safe and equipment is maintained. The home was clean and hygienic with no unpleasant odour apparent despite most patients being incontinent. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 Staffing levels are appropriate to the needs of the people accommodated, and training is provided to ensure staff assist patients in a safe manner. EVIDENCE: The staff rota was examined, and this provided evidence that sufficient staff are deployed in the home. There has been some turnover of staff recently but this has now become more stable. There is some dependency on agency staff, but this is managed by ensuring that it is the same people who come from the agency to offer consistency for the patients. The inspector spoke to staff who said that there was always time to spend with patients and that this seen as part of their role. Patients spoken to confirmed this, and one said “these staff are the best.” A sister who requires two people to assist her to move confirmed that this was never carried out by less than the required two staff. Recruitment was found to be generally professional, but this could be improved by obtaining a CRB instead of accepting one carried out by a previous employer, as these are no longer portable. Training is given priority as there are seven care staff of whom two have completed NVQ level II in care and two have completed NVQ level III. A further two have enrolled to undertake level II in September. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 17 Induction records were viewed and confirmed that staff always work with a mentor for two weeks in order to become familiar with patients and routines of the home. This was confirmed by two new members of staff who both commented that they felt very supported by the matron and other staff during that period and since. Training is provided in fire safety, moving and handling and palliative care. Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 38 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. She is currently undertaking the Registered Managers Award. One staff member commented that she felt “valued and respected” by the manager and is treated accordingly. A letter received from a relative states “The dedication and tireless work of the matron, Sister Catherine, is evident and by her relationship to both residents and staff she sets the ethos and standard of care that ensures the wellbeing of all the residents.” Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 19 The matron is currently undertaking the registered Manager’s Award and hopes to complete this in a few months. All staff receive daily supervision from the matron, and this is to be developed by introducing more formal 1-1 sessions with staff to discuss development Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 3 3 x x 2 x 3 Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? 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 29 Regulation 5 Requirement A new CRB shold be obtained for new employees prior to employment as these are no longer portable. Timescale for action 30/06/05 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. 4. Refer to Standard 3 Good Practice Recommendations A more detailed pre admission assessment should be obtained prior to agreeing to admit a patient in to the home. The registered manager should complete the Registered Managers Award. It is recommended that a written record is kept of formal 1-1 support sessions. 31 36 Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 22 Commission for Social Care Inspection Area Office, Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cross & Passion Nursing Home CS0000006082.V160749.R01.doc Version 1.30 Page 23 - 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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