Inspection on 25/01/07 for Elmleigh Convent

This inspection was carried out on 25th January 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

Elmleigh Convent 09/03/06

Elmleigh Convent 08/09/05

Elmleigh Convent 24/11/04

Elmleigh Convent 13/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Elmleigh Convent Kings Road Ilkley West Yorkshire LS29 9AT Lead Inspector Paula McCloy Key Unannounced Inspection 25th January 2007 10:30 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 Elmleigh Convent DS0000001163.V327380.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. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmleigh Convent Address Kings Road Ilkley West Yorkshire LS29 9AT 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) 01943 607003 01943 604576 Sisters Of The Cross & Passion Mrs Jane Parkinson Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (10), of places Physical disability over 65 years of age (2) Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As identified in the notice dated 31 October 2003 Date of last inspection 9th March 2006 Brief Description of the Service: Elmleigh Convent is conveniently located a short walk away from Ilkley town centre and a local bus route. It is registered as a care home and accommodates up to sixteen retired sisters of the Cross and Passion. Attached to the home is a chapel that is also open to the local community. This large detached building has extensive grounds including a boating lake no longer in use. There are ample parking facilities within the grounds including a convenient area in front of the home and chapel. There are a number of large communal rooms mostly located on the ground floor. A passenger lift provides access to all floors apart from the second floor where there is accommodation that visiting relatives and friends can use. Single bedrooms are available located on the ground and first floors. Many have en-suite facilities. The current weekly charge is £440. Additional charges are made for hairdressing and holidays. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection of the home took place on 9 March 2006. There have been no further visits to the home until this key inspection. This inspection was carried out to assess the quality of care that people living at the home are receiving and to check what progress had been made on meeting the requirements from the previous inspection visits. I carried out the inspection over a day and spent approximately 7 hours in the home. The home only provides care and accommodation for retired nuns from the order of the Cross and Passion, who are referred to as ‘sisters’ so this terminology has been used in this report rather than residents or service users. The methods used in this inspection included discussions with 5 sisters, 6 staff, the manager, observation of care practice, examination of records, and a partial tour of the home. A pre-inspection questionnaire was sent to the home prior to this visit asking for information. This questionnaire was returned and the information provided has been used in this report. Comment cards were sent to the sisters and a GP; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. Five sisters and one GP wrote to the inspector with their comments. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Staff at the home continue to provide a high standard of care and support to the sisters that live there. The homes own quality assurance systems make sure that staff are continually reviewing and improving their service. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 7 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. Elmleigh Convent DS0000001163.V327380.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 Elmleigh Convent DS0000001163.V327380.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 does not apply) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Any sister that wants to live at Elmleigh is visited and assessed by the manager. This makes sure that staff at the home can meet that sisters needs. EVIDENCE: Elmleigh was a working convent before it became a care home. All of the residents living there are members of the Sisters of the Cross and Passion. In previous times it was used for holidays by the sisters. Many of the sisters who live at the home now remember going there for their holidays. Any sister that needs to move into the home is assessed by the manager. The manager will visit them in their current convent and tell them about Elmleigh as it is now as a care home. The manager completes a full assessment so that Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 10 she is sure staff can meet the sisters needs. One of the sisters said ‘‘I had a visit from the manager telling me all about Elmleigh and what they do for the people that live there.’ Two assessments were examined. These were very thorough and detailed. The assessments also included things that needed to be done following admission. For example one assessment identified the need for a dental appointment. A note was made that this should be done after a few weeks so that the sister could settle in first. The home does not provide intermediate care. Elmleigh Convent DS0000001163.V327380.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. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and give staff the information they require to meet the sisters’ needs. The health care needs of the sisters are being met with health care professionals being involved as necessary. Medication is well managed which promotes good health. EVIDENCE: Care plans are well organised and it is easy to find the relevant information quickly. The care plans set out in detail what action needs to be taken by staff to ensure the sisters’ needs are met. Staff are vigilant and new care plans are developed as peoples needs change. Details of the sisters’ interests and preferred routines are also noted. For example details of what time each sister likes to get up and if they want breakfast in bed is in their care plan. Care plans are being reviewed on a monthly basis and there was evidence of Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 12 individual sisters being involved in the planning process. There are also more formal annual reviews that involve the individual sisters in planning their future care and support. Two of the sisters said ‘the care and support is excellent.’ The sisters’ health care needs are being identified and met. Staff are vigilant and GPs and other health care professionals are being involved as necessary. Care plans clearly document each visit by a health care professional and advice that has been given. The personal hygiene and oral hygiene needs of the sisters are clearly documented in the care plans. The doctor said ‘very caring home who keep patients even when very ill or weak, they cope with all calamities! No worries at all.’ Three of the sisters made the following comments about their care ‘I always get the medical support I need and quickly.’ ‘I have been four months here. Since I have been here I have been 4 or 5 times to the medical centre. The chiropodist calls for anyone who needs him. I have an appointment with the dentist in February 2007.’ ‘During the time of my stay, renewal of medication was the support I needed, this was done without fuss.’ There is a mutual respect between staff and the sisters. All of the staff said that the sisters can have whatever they want. All of the sisters have their own room and can have a telephone if they want one. There is no charge for any calls they make. All of the sisters have their own bed linen. The doctor confirmed that he can see his patients in private. Medication records are well maintained and show that residents are getting their medication at the prescribed times. Some of the sisters look after their own medication. The necessary risk assessments have been completed and the sisters have somewhere in their rooms to lock their medication away. The sisters all looked smart and well cared for. From observation any personal care that was offered by staff was completed in a respectful and dignified way. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 13 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. This judgement has been made using available evidence including a visit to this service. Social activities at the home are being provided consistently to keep the sisters stimulated. Relatives and friends are welcome to visit at any time. The sisters are able to bring personal possessions with them on admission. The sisters are consulted about their preferred routines and these are documented in the care plans, so staff can make sure peoples choices are maintained. The meals at the home are very good offering choice and variety. EVIDENCE: The home has its own Chapel and the sisters attend religious services in the mornings and afternoons. Some of the local parishioners also use the Chapel and the sisters enjoy their visits. The home also employs an activities co-ordinator who works two days per week. She will take the sisters out shopping or on trips. Activities are also arranged in the home with the sisters making various items to sell for charity, Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 14 playing board games, knitting or anything else they may wish to do. Recently a questionnaire has been given to all of the sisters to ask them about the activities and if there is anything else they would like to suggest. Daily newspapers are delivered and one of the sisters enjoys the talking books and newspapers that she receives. On the day of the visit some of the sisters went out for a walk either with a member of staff or on their own. Two of the sisters made specific comments about the activities ‘the activities organiser is at pains to provide a variety of activities to suit all tastes.’ ‘Elmleigh is an excellent care home. Christmas and New Year get-togethers are happy times. Regular celebrations during the year.’ Relatives, friends and visiting sisters are welcome at any time. The home has accommodation that visitors can use if they want to stay over night. There is a kitchenette on the first floor that the sisters can use to make drinks and snacks if they wish. Meal times at the home are very social occasions. At lunchtime the tables were beautifully set and fresh flowers were on every table. Following the soup the roast chicken and roast potatoes and vegetables were served on plates and terrines at each table so that the sisters could help themselves to as much or as little as they needed. Staff were available to assist where necessary. The choice of desserts were placed on a table in the dining room, together with a selection of fresh fruit. The sisters again helped themselves or were assisted by staff. All of the sisters said the food was excellent and three made specific comments ‘I have diabetes and my needs are acknowledged, fruit is readily available. Catering staff provide meals to tempt all tastes.’ ‘More food than I usually had in my convent!’ ‘Excellent home cooked meals, well planned beforehand. Beautifully presented and served with a smile.’ Staff also eat their meals at the home and one said ‘the food is too good and no good for my waistline!’ One of the sisters hasn’t got a good appetite. Staff have consulted the dietician and fortified milk is used in her tea and regular fortified drinks are given throughout the day. On their feast day the sisters choose their favourite meal and this is prepared for them. The cook is well aware of the sisters individual likes and preferences and the sisters talk to her about the meals. One of the sisters had asked for her meat to be blended. This request had also been documented in the care plan and arrangements made for this to happen. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. The sisters’ views are listened to, taken seriously and acted upon. Staff have a good understanding of adult protection issues, which protects the sisters from any abuse. EVIDENCE: The sisters all stated that if they had any concerns that they would feel able to talk to the manager or another member of staff. They were also confident that any issues raised would be resolved. One of the sisters said ‘the manager/deputy readily available to listen and to act.’ There is a written complaints procedure in place, which needs to be updated so that it includes details of the timescale within which complaints will be responded to. The manager is also aware that she needs to keep a log of any complaints that are received that gives details of the date, complaint, action taken and outcome. Staff have attended adult protection training and the local adult protection procedures are available. All staff spoken to were able to detail exactly what they would do if they felt any practices in the home were not in the best interest of the service user. Elmleigh Convent DS0000001163.V327380.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): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, safe, comfortable, well-maintained home. EVIDENCE: Elmleigh is situated in a residential area of Ilkley. It is set in its own large, well-kept grounds. The home employs a caretaker who deals with the day-today repairs and on going maintenance. The home is well maintained, clean and comfortable. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 17 The home was clean and tidy on the day of the inspection. All of the sisters said the home was always kept clean and fresh. One of the sisters said ‘the cleaning staff do an excellent job. Bed linen etc is changed weekly or more frequently if necessary.’ There are infection control procedures in place. There have been no infection control issues at the home since the last inspection. The laundry is well equipped, clean and tidy. The required ‘non return’ valves are in place on the washing machines. Elmleigh Convent DS0000001163.V327380.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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff morale is good resulting in an enthusiastic workforce that work positively to improve the sisters’ quality of life. Staff are receiving appropriate training to meet the sisters needs. Any new staff are thoroughly checked to ensure that they are suitable to work with older people. EVIDENCE: The duty rotas were examined. These show that during the day there is one senior staff member on duty with one care assistant during the day. At night there are two care assistants on duty with the manager ‘on call’ who can be called if an emergency arises. There is cook, domestic and kitchen assistant cover during the day. Care staff cover the laundry duties. Staff said that at the current time the numbers of staff on duty were adequate to meet residents’ needs. Staff also said that if any of the sisters needs change more staff are organised as necessary. The manager and deputy manager work mostly supernumerary to the rota, which means that during the week there are usually three or four staff of duty. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 19 All staff spoken to felt that they were working well as a team and that they enjoyed coming to work. One member of staff described the home as ‘unique’ and said that she loved working at the home because she had time to do her job properly. Agency staff are used to cover some shifts, these tend to be the same staff who are familiar with the home. There are 33 of the care staff qualified to NVQ level 2 in care. There are care staff at the home who are in the process of completing this training, when they complete their awards the home will have 50 of its care staff qualified. Two staff files were examined. Recruitment procedures are robust. Staff files confirmed that the necessary checks are being completed to ensure the suitability of new staff. All new staff receive induction training and records of this training are maintained. The most recently recruited member of care staff confirmed that she was in the process of completing this training. Elmleigh Convent DS0000001163.V327380.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): 31, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the sisters. The sisters are involved in the running of the home and about their care and support. Practices in the home promote the health, safety and welfare of the sisters. EVIDENCE: The registered manager is in the process of completing the registered manager award. She keeps herself up to date by attending additional training courses and seminars. Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 21 The sisters are consulted about the running of the home at community meetings, through the annual quality assurance questionnaires and at the reviews of their care plans. Before Christmas the sisters and staff arranged a Christmas Fayre the proceeds from which are given to charity. The sisters at one of the community meeting decided on the charity they wanted the money to go to. At the beginning of the year each sister decides how much money she wants for clothing, holidays and for personal expenses. This money is put into Elmleighs funds and is administered by the Sister Superior. The manager said that there is no problem if a sister wants some money then she gets it. There is a written Health and Safety policy. Staff receive moving and handling, food hygiene, fire safety, health and safety, first aid and infection control training. The fire alarms are tested weekly and fire drills/practices are held. The passenger lift and moving and handling equipment service records were all seen and were up to date. Elmleigh Convent DS0000001163.V327380.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 X 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 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Elmleigh Convent DS0000001163.V327380.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 OP16 Regulation 22 Requirement The complaints procedure must be up dated and give information about the timescales within which any complaint received will be responded to. Timescale for action 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmleigh Convent DS0000001163.V327380.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Elmleigh Convent DS0000001163.V327380.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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