Inspection on 08/09/05 for Elmleigh Convent

This inspection was carried out on 8th September 2005.

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 25/01/07

Elmleigh Convent 09/03/06

Elmleigh Convent 24/11/04

Elmleigh Convent 13/07/04

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Larchfield Manor

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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 Susan Knox Announced 08 September 2005 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. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elmleigh Convent Address Kings Road, Ilkley, West Yorkshire LS29 9AT 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) 01943 607003 01943 604576 Sisters of the Cross & Passion Sister Moya OCleary Care home only 16 Category(ies) of Old age (10), Dementia over 65 (4), Physical registration, with number Disability over 65 (2) of places Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24 November 2004 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 is 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 pasenger lift provides access to all floors apart from the second. Single bedrooms are available located on the ground and first floors. Many have en-suite facilities. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspection officer carried out this announced inspection. This began at 9.45 am and finished at 3.15 pm. The registered manager completed pre inspection forms in time for the inspection. Time was spent talking to service users, staff and observing care practices. Records were checked including care records, recruitment records and staff training records. Feedback was given on the findings to Sister Nora the responsible person, Sister Moya manager and Jane Parkinson deputy manager. What the service does well: What has improved since the last inspection? The number of night staff on waking duty has increased to two. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 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. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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 Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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, 4, 5. Service users are assessed to ensure their needs can be met and know they will be well cared for in the home. EVIDENCE: The sisters of the Cross and Passion are a long-standing community who have previously worked countrywide and abroad. For many years the sisters carried out work in other communities and spent time at Elmleigh using it as a retreat or paying visits to their colleagues and friends. Therefore many who retire there are familiar with the building, routines and the local area. Some said that although reluctant to give up their work out in the community they knew that their needs would be catered for at Elmleigh. The deputy manager advised that all service users are assessed before admission to the home. This assessment is recorded and forms part of the initial care plan. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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, 9, 10. Care planning is good, well documented and up to date. Health care needs are met. Policies and procedures relating to medication are followed in order to protect service users. The right to privacy and dignity is upheld in the home. EVIDENCE: Since the last inspection a new system of care documentation has been introduced to good effect. Repetition of records has been reduced and the system is user friendly. Three sets of care documentation were reviewed. In the first instance longterm care planning is established followed by short term. Evaluation takes place ensuring that any changes are identified and appropriate action taken. The care plans are reviewed and updated monthly or more often if required. Care planning was well documented and up to date. During discussions staff and some service users were able to confirm that care needs were met. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 10 Evidence was available about the service user involvement in care planning. This was also confirmed during discussions with service users. The service user (if possible) signs a form indicating discussions about the care plan. It was evident from records and from discussions with staff that the health needs of service users are under constant monitoring. Staff were aware of individual health needs. The records show that every attempt is made to resolve health issues with help from the district nursing service or other health professionals. The home operates with a monitored dosage system (MDS). Records of medication was checked and found to be satisfactory. Medication that is not part of the MDS is checked into the home, as required. Records are kept for medication returned to the pharmacist for disposal. Some service users selfadminister medication following an assessment. Most staff have attended the advanced accredited medication training. From observations it was apparent that privacy and respect was routinely offered as part of the daily routine. Doors were always knocked on and enquiries to those needing help with personal care was discreet. Service users spoke well about the care provided by staff. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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) 12-14 Activities are individually focused on service users needs and preferences. A programme of activities is provided for residents including trips out. Service users are fully involved in the routine of the home, in religious matters and the community. EVIDENCE: A new activities coordinator has been employed since the last inspection. Activities are varied and individually tailored to meet the needs of service users. These range from walks or bus rides to the town to a number of in house events such as coffee mornings or Hokey Cokey. The procedures for daily routines show the emphasis that management have on staff spending individual time with residents. This can be helping with letter writing, reading or assisting those who prefer a walk out. Many visitors call at the home and some stay overnight in the visitor’s rooms. The service users and staff always greet visitors warmly and ensure that hospitality is offered. The comments in the visitor’s book, letters and cards show that relatives are pleased with the care provided in the home. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 12 Community meetings are regularly held one due for the week following the inspection. Along with religious events and changes the service users are involved in house discussions. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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) 16, 17 An open forum is provided for service users to speak about any concerns. The home has prepared well in order to protect service users from abuse. EVIDENCE: No complaints have been received. Management is aware that any made would need to be investigated. Community meetings are one venue available for service users to speak out. During discussions it was clear that they would approach the manager with any concerns. In addition Sr. Nora as the responsible person also sees service users individually on her visits to the home. This was observed on this inspection. During discussions staff understood that any concerns would be reported to management. Abuse training had been attended. The deputy has attended a course Adult Protection Awareness level 1. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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) 22, 26 The home meets the needs of service users by providing specialist equipment as necessary. Cleanliness and odour control in the home is to a very high standard. EVIDENCE: A full inspection of the building was not carried out. However from the rooms and areas seen when talking to service users the environment is very well maintained. Recently the widow frames in bedrooms have been replaced by double-glazing units. This was greatly appreciated by service users. The fire alarm system has been replaced. The equipment in the home meets the needs of the service users. If needs change and additional equipment is required then this is obtained. A mobile hoist, HI LO baths, profile beds, wheel chairs and personal aids are available. One corridor is ramped and a passenger lift ensures easy access to all floors. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 15 Bathrooms and WC’s were clean and hygienic with liquid soap and paper towels available. Other rooms such as communal rooms and bedrooms were also very clean with good odour control. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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) 27-30 Management are proactive in changing staffing levels in order to meet individual needs. Staff receive induction and the training necessary for providing care to older people in order to meet the needs of the service users. In order to completely safeguard the service users information about new staff and CRB checks must be seen before they start work. EVIDENCE: Staff rotas were made available before the inspection. A recent change has been to increase staff levels on nights to two working staff. This was done in order to meet the needs of service users. Five staff have achieved NVQ level 2 or more. This means that 33 of the total number of care staff have received this training. Recruitment records were checked for the latest staff. Evidence was available that references were taken up and identification established. Criminal Bureau Records (CRB) checks were undertaken but staff were set on to work before receiving clearance. One was agreed with the CSCI but clearance must be obtained before new staff begin to work in the home. Discussions were held about obtaining POVA first clearance. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 17 Records show that staff have completed induction and training. The deputy discussed whether staff had to attend an external foundation course. Foundation training does not have to be an external course unless one of the components cannot be provided internally. All new staff complete an induction programme. This was confirmed in discussions with staff who said that four shifts had been worked before starting duties. It was also confirmed that part of the induction covers discussions about the ethos of the home. Three members of staff currently hold a first aid certificate. Training records showed that training is ongoing and there is an obvious commitment to ensure the needs of service users are met and their health and well-being is protected. Further training is planned for in the coming months. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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, 35, 38 The home is well organised and the manager provides effective leadership. Service users are encouraged to participate in all aspects of the home and there are good systems of communication in place. Health and safety of service users and staff is promoted and protected. EVIDENCE: Staff and service users spoke well about the management of the home. Sr. Moya O’Cleary has extensive management experience and provides effective leadership. Service users hold her in high regard and find her very approachable. The management of the home is moving towards a change with the deputy Mrs Parkinson applying to be jointly registered as manager with Sr Moya. The service users are being kept well informed about the change. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 19 Staff meetings and community meetings are held regularly. These are documented. The records of monies retained for safe keeping were well kept. Records were kept of all transactions. The deputy manager has undertaken a satisfaction survey as part of her RMA course. The results were available and showed a high degree of satisfaction. The management of the home respond positively to requirements and recommendations made by different agencies. The pre inspection questionnaire showed that health and safety checks were up to date therefore none of these records were inspected. Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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 3 4 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 x COMPLAINTS AND PROTECTION x x x 3 x x x 4 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 4 x 3 x x 3 Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 21 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 19 Requirement The manager must ensure that police and POVA clearance is obtained before new staff start work. Timescale for action With immediate affect. 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. Refer to Standard Good Practice Recommendations Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Elmleigh Convent 20050808 Elmleigh Covent An Stage 4 S1163 V234665 J52.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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