Inspection on 09/03/06 for Elmleigh Convent

This inspection was carried out on 9th March 2006.

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 08/09/05

Elmleigh Convent 24/11/04

Elmleigh Convent 13/07/04

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Snydale Care Home

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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 Susan Knox Unannounced Inspection 9th March 2006 10:00 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.V284540.R01.S.doc Version 5.1 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.V284540.R01.S.doc Version 5.1 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.V284540.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. As identified in the notice dated 31 October 2003 Date of last inspection 8th September 2005 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. Single bedrooms are available located on the ground and first floors. Many have en-suite facilities. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector and completed in 5.5 hours. The inspection focused on discussions with service users. In addition talks were held with staff and observations of working practices carried out. Some records were reviewed including care documentation, supervision reports and the staffing rota. Service users and staff gave very positive feedback about the care in the home. What the service does well: What has improved since the last inspection? Staff said the new care planning documentation is an improvement and is more easily used as a working tool by care staff. Management and staff training are ongoing. Care staff supervision is well developed. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 DS0000001163.V284540.R01.S.doc Version 5.1 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 Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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): 1, 2. Prospective service users/relatives are given sufficient written information about the home. EVIDENCE: The service users in this home are sisters in need of care who are members of the Sisters of the Cross and Passion. Many service users are very familiar with the home and the local area. The home was a working convent and was used for the sisters to work in the community and for retreats. The statement of purpose/service user guide provides clear information about the ethos of the home as it is now. There is sufficient information about the home and the service it gives to enable people to make an informed decision about moving in. A copy of the updated document was given to the CSCI. This reflected changes in personnel. The Deed of Covenant that is agreed with individual sisters on entering the order of the Sisters of the Cross and Passion has been accepted by the CSCI in place of terms and conditions. In addition for those sisters funded by the local authorities contracts are available. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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): 7, 11. Care planning is good and meets the needs of service users. The care of those terminally ill is carried out with respect and in accordance with last wishes. EVIDENCE: The new system of recording care is now well established and was said to be working well. Care staff said care plans were clearer and more readily accessible. Three sets of care documentation were case-tracked. Care planning has continued to improve since the last inspection and was person centred. Plans were clearly updated as needs changed and also evaluated monthly. Advice in a written report from a health professional for one service user was implemented. Evidence was available that where possible the service user is included in the care planning. Risk assessments were in place such as moving and handling and self-administering medication. Discussions were held about the use of nutritional assessments and repositioning charts when necessary. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 10 The care of those terminally ill was discussed. It was confirmed that constant care and comfort is provided in accordance with advice from the GP and the community nurses. Staff confirmed this in discussions. Care plans are amended as necessary. If required additional staff will be employed to ensure constant attention is given. Relatives are kept informed and some stay overnight in the separate accommodation that is available. Service users confirmed this in discussions. As the sisters are former colleagues and friends any last wishes are well known. In addition to relatives the other service users are fully involved by sitting with their ill friend and in prayer. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 the following standard(s): 12, 15 The service users benefit from well organised activities that not only stimulate but also enable them to remain as part of the religious community. Service users receive well-prepared nourishing food that they enjoy. Meal times are social events. EVIDENCE: The activities coordinator was in the home at the time of inspection. This is a regular weekly event and time is spent in small group work or individually. At the time the sisters were preparing to celebrate St. Patrick’s Day. Activities are varied and range from walks around the grounds to trips into the town to shop. Longer trips are organised in the warmer months and some of the sisters take holidays away from the home. Community meetings are regularly held and the service users are involved in discussions such as about changes within their Order. Retreats are regularly organised the most recent was to discuss in depth The Gospels. This was thoroughly enjoyed by the sisters. Service users confirmed in discussions they were very happy with the activities. Talking books were described by one service user as a way of remaining in touch with the local and religious community. She enjoyed listening to the Ilkley Gazette and to a Catholic paper. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 12 Meals are provided in a spacious very pleasant dining room where all the service users come together. Meal times are part of the social events within the home and most days there are visitors present as well. Many service users are provided with breakfast in their rooms. Discussions were held about individual needs and for one the arrival of a full tray was out facing so this was re organised to good effect. The service user confirmed this in discussions. Four weekly menus are in use and these are regularly changed after discussions with the service users. On the day of the inspection a full roast dinner was being prepared followed by a choice of desserts. Fresh fruit was available in the dining room. Service users said that the meals are excellent, well cooked and with choice readily available. Feast days are regularly held and individuals can choose to have their favourite meals prepared. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 the following standard(s): 18 Relevant staff training and the ethos of the home ensure that the service users are kept safe. EVIDENCE: Staff confirmed that training in how to recognise abuse has been held. This is also discussed with new staff during their induction. This induction also covers the ethos of the home and the importance in putting service users needs first. The manager has attended an Adult Protection Awareness level 1 course. The local authority guidance in Adult Protection ‘No Secrets’ was readily available to staff. During discussions staff said that they would have no difficulties in speaking out and understood that any concerns should be reported to management. It was apparent from discussions with service users that they were very comfortable about talking to staff regarding any concerns. The majority of the staff were known to them by name. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 the following standard(s): 19-25. The home provides very comfortable accommodation and the building is regularly well maintained. The home is clean. Service users are enabled to remain independent by the availability of individual aids in different parts of the building. Service user’s rooms are personalised and comfortable. EVIDENCE: The building stands in its own grounds. The gardens are well kept and the service users enjoy their short walks around the gardens. There is level access into the building through a side door for wheelchair users. A ramp is in place near the dining room for ease of movement. A passenger lift provides access to all floors apart from the second floor reading room. The providers ensure the home is well maintained. A random check of some bedrooms and bathrooms was carried out. All areas were well furnished, clean and had good odour control. The quality of furnishings, linen and bedding was Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 15 to a high standard. Some service users preferred to keep their room doors locked and a lockable facility was seen in the rooms. Discussions were held with some service users in their rooms. Those who were able said that they liked their rooms and were very comfortable there. Many had personal possessions displayed such as photographs and pictures. They confirmed that care staff respected their privacy. Some bedrooms have en suite facilities and there is a wide range of bathrooms located in all areas of the building. The home has a number of specialist equipment in place to ensure that service user’s needs could be met. A Hi Lo bath is available and a walk in/wheel chair friendly shower facility is located in one bathroom. A number of profile beds have been provided to ensure the service user’s comfort even though no nursing care is provided. Staff confirmed that they have no problems with availability of equipment. Anything that is requested is readily supplied. Special individual needs are met for example in the provision of talking books and a clock. To maintain the independence of one service user, a Braille sign has been fitted to indicate the floor level on leaving the lift and an additional knob to the last step of the staircase. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 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, 28. Staffing levels are sufficient to meet service users’ needs but early evening shifts may need to be reviewed. There is a good skill mix in the staff team. Management ensure that staff receive NVQ training so that they can carry out their jobs. EVIDENCE: A copy of the rota for the week was seen during the inspection. There have been some recent changes with the appointment of a deputy manager. This is a registered nurse who was aware that nursing practices could not be carried in this care home. There are also forthcoming changes with senior care staff leaving to take up nurse training. Due to this a senior care has been appointed senior care co coordinator and three new senior care staff appointed. Up to these changes the staff team has been long established with very few changes taking place. There is a good skill mix of mature and younger staff that has attended various training courses in order to meet the needs of service users. Care staff confirmed this. Staffing levels reflected the independence of many of the service users. A recent change has been to increase staffing levels on nights to two waking staff rather than one sleeper and one waking carer. The manager was asked to review the staffing levels during early evening time when staff numbers are particularly light. At the time of the inspection the numbers and needs of a small group did require constant monitoring at this time. Staff confirmed during discussions that the home was well staffed. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 17 The manager confirmed that four senior care staff have achieved NVQ level 3 and four new staff are due to enrol on the NVQ level 2 course. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 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, 34, 36, 37. The home is well organised and management provides effective leadership. Ongoing training ensures they are kept updated about current care practices. The regular supervision of care staff ensures that their development in care practices is monitored and the needs of service users are met. Well-maintained record keeping means that service users are kept safe. EVIDENCE: Since the last inspection the home has now got two registered managers. Sr. Moya O’Cleary has extensive management experience and Mrs Jane Parkinson has worked as the deputy of Elmleigh for many years. Both have attended many training courses that enable them to meet the needs of the service users. Mrs Parkinson is near to completing the Registered Manager’s Award and NVQ level 4. The deputy manager is due to start the same course in September. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 19 Staff and service users spoke well about the management of the home and how they provide effective leadership. An up to date public liability insurance certificate was displayed in a public place in the home as required. Care staff receive regular supervision and these records were available. This was confirmed in discussions when staff said they had no difficulties in speaking out during supervision or in staff meetings. Sessions are well developed and the manager has attended a training course. The records reviewed during the inspection were well kept, up to date and stored appropriately to ensure service users’ confidentiality. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 4 4 4 4 4 4 4 X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X 3 X 3 3 X Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 Page 21 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. 1 Refer to Standard OP27 Good Practice Recommendations Review the early evening care staffing levels. Elmleigh Convent DS0000001163.V284540.R01.S.doc Version 5.1 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. 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