Inspection on 16/04/07 for Franciscan Convent

This inspection was carried out on 16th April 2007.

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

Franciscan Convent 15/03/06

Franciscan Convent 08/11/05

Franciscan Convent 24/02/05

Franciscan Convent 10/08/04

Franciscan Convent 12/03/04

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

CARE HOMES FOR OLDER PEOPLE Franciscan Convent 63 Yorkshire Street Burnley Lancashire BB11 3BS Lead Inspector Mrs Pat White Key Unannounced Inspection 16 th April 2007 11:30 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 Franciscan Convent DS0000009534.V332883.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. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Franciscan Convent Address 63 Yorkshire Street Burnley Lancashire BB11 3BS 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) 01282 459090 01282 439012 Franciscan Missionaries of St Joseph Mrs Janet Crawford Care Home 25 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (22) of places Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: The Franciscan Convent is registered to provide care and accommodation to 25 older people, including 3 older people with dementia. The Convent belongs to the Roman Catholic Order of the Franciscan Missionaries of St Joseph, and has been adapted to a care home. Only retired Sisters Religious needing care from this Order live in the home at the present time. The Roman Catholic faith underpins the life of the home and Mass is celebrated daily in the Convent’s Chapel. The premises are an older Convent building, in the centre of Burnley, which has been well adapted to its dual function of Convent and care home. It comprises 3 floors, linked by a lift. There were 20 bedrooms, which at the occupancy levels at the time of the inspection, were all used as single rooms. There were 10 WCs, 4 baths, three of which were assisted baths, and two showers. None of the bedrooms were en suite. There was extensive communal space which included: a large lounge / dining room, a conservatory, a library, a T.V. lounge and a visitors lounge on the ground floor and a “day room” on the first floor. The Franciscan Convent had a Statement of Purpose and a Service User Guide providing information about the care provided, the facilities, and the qualifications and experience of the manager and the staff. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at the Convent on the 16th April 2007. The purpose of this inspection was to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People, and checking the progress made on a few matters that needed improving from the previous inspection. The inspection took 6 hours and 30 minutes and comprised of, talking to some Sisters, a tour of the premises, looking at Sisters’ care records and other documents, and discussion with the manager, Mrs Crawford and the Senior Assistant Manager. A pre - inspection questionnaire (PIQ) was completed and information from this is included in the report. Five Sisters were spoken with and seven Sisters completed comment cards. Some views and comments they expressed are included in this report. What the service does well: The Convent has consistently over time provided a high standard of care. The Sisters were well cared for by a staff group who understood their physical needs for care and also their needs as Sisters of a Religious Order. Sisters praised the staff for being kind and understanding. The written information about the Sisters’ needs and how these needs were to be met was detailed and well written. Their personal and health care needs were well monitored and addressed and medication was managed safely to ensure that the correct medication was given. The way the home was managed and run enabled the Sisters to continue their religious and Convent life. Sisters regard the Convent as “their home” rather than as a “care home”. Appropriate activities and routines were maintained and encouraged. There was a computer for the Sisters’ use and some were having tuition. Some of the Sisters were independent and organised activities for themselves and other Sisters. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 6 The food served in the home has consistently over time been of a high quality and which met the Sisters’ preferences. Sisters’ spoke positively of the meals served, though recognising that “you can’t please everyone all the time”. There were good opportunities for staff training, which were in line with Government guidelines and which ensured that the staff had the right knowledge and skills, including training in looking after those with dementia. The home was very well maintained and decorated and provided a comfortable, peaceful, spacious and safe environment for the retired Sisters. Refurbishments and maintenance were carried out when needed and prioritised through a planned programme. There have consistently been sufficient members of staff on duty, with sufficient skills, to meet the needs of the Sisters. The home was following thorough recruitment procedures that complied with the legal requirements. This helped to ensure that only suitable people were employed in the home. The home has benefited from a stable long serving “management team” of which the present manager has been a part, and this has helped to ensure consistent high quality care. The Sisters interests were further protected by the presence of a resident “Community Leader” and regular visits from members of the Congregation. What has improved since the last inspection? The written information about the Sisters’ care needs and how these were to be met had been further improved, and the constantly changing needs of one Sister, were being reviewed and updated as necessary. This ensured that the staff always understood what they needed to do to maintain the high standard of care. Some of the legal requirements made at the previous inspection about medication management had been met. Since the previous inspection the manager was informing the Commission about accidents and incidents affecting the health and welfare of the Sisters so that the Commission could monitor this. Franciscan Convent DS0000009534.V332883.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. Franciscan Convent DS0000009534.V332883.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 Franciscan Convent DS0000009534.V332883.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, 4 & 5. Standard 6 was not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was useful written information about the home’s accommodation and facilities, to inform the resident Sisters and prospective Sisters. The physical and spiritual needs of the Sisters were met. EVIDENCE: There was sufficient suitable written information about the Convent to meet the needs of the Sisters and prospective Sisters who were considering going to live there. The admission procedures were appropriate for Sisters from the Congregation who needed care or support in a care home setting. Sisters were asked if they wanted to go and live at the Burnley Convent and could spend time there meeting the other Sisters and staff. However Information about the Sisters’ needs was not usually written down until they went to live in the home, neither were the details about the pre-admission visits. This was not Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 10 particularly detrimental for the recently admitted Sisters who did not have many care needs, but would not be suitable for those Sisters who were dependent with various care needs. In this situation a pre-admission assessment would be desirable so that staff would understand the needs and how they were to be met. The Sisters had wide ranging diverse needs; from those who were relatively independent and could go out alone, to those with high dependency care needs. The Convent could also accommodate 3 Sisters with needs relating to dementia. The inspection methods used indicated that the varied needs of the Sisters were being met. Some members of staff had completed training on dementia care to assist them understand these needs. The Sisters spoken with said that staff were patient, kind and understanding and understood their needs. Franciscan Convent DS0000009534.V332883.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 good. This judgement has been made using available evidence including a visit to this service. The care plans were well written and contained useful detailed information about the Sisters needs and how these needs should be met. The Sisters’ health and personal care needs were well monitored and fully met and in general medication practices were safe and ensured Sisters received the correct medication. EVIDENCE: All the Sisters had comprehensive care plans. Those viewed were well written, and contained useful information on the Sisters’ health, personal and social care needs. There was evidence that care plans were regularly reviewed and updated, and those Sisters who wished, were involved in this process. Relevant risk assessments had been undertaken, including moving and handling, risk of falls, the use of bedrails and vulnerability to pressure areas. The intervention and preventative measures for pressure areas were recorded Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 12 on the care plans, and appropriate assistance and equipment was given from the District Nurses. However a member of staff was observed moving a Sister in a wheel chair without the use of the foot - rest. There was no supporting risk assessment to demonstrate this was a safe practice. Relevant details about dementia and mental health issues were also recorded on the care plans. Nutritional screening was carried out as part of the care plan. The records viewed, and discussion with the manager and Sisters, showed that the Sisters’ physical and psychological health was well monitored and maintained. The more independent Sisters made their own arrangements for health care. The staff and the Congregation supported the Sisters who needed assistance. Sisters spoken with and those who completed questionnaires felt that they had the care and support they needed. Of the 7 Sisters who completed questionnaires 5 said that they “always” got the medical support they needed and 2 said “usually”. Five Sisters said they “always” received care and support when needed and 2 said they “usually” did. The Sisters’ medication was managed safely and some previous requirements had been met. Medication policies and procedures were checked at a previous inspection and found to be in accordance with the Royal Pharmaceutical Society guidelines. Areas of good practice included: Prescriptions being checked for errors prior to dispensing, photographs used as a means of identification, lockable fridge to store medication requiring storage below room temperature. However several Sisters were responsible for their own medication but this was not underpinned by a risk assessment at the time of the site visit. This was rectified shortly after the site visit. In general the Medication Administration Records (MARs) and other records were well kept and accurate, and the criteria for when to administer “when required” medication was written on the care plan. However criteria for which dose is to be given for “variable dose” medication were not explained and recorded. Also one MAR viewed was not an accurate record of the medication being administered – there was a repeated entry of a medication that was no longer being administered. For one Sister whose records were viewed the dose administered of one medication was not the same as that written on the MAR or the medication label and there was no supporting written instructions or explanation from the General Practitioner. The Sisters felt that their rights to privacy and dignity were respected and it was clear that staff understood the importance of these rights. Franciscan Convent DS0000009534.V332883.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. The lifestyle, activities and choices in the home matched the Sisters’ expectations, including those associated with Religious Life. The food served was varied, appetising and healthy and met the Sisters’ preferences. EVIDENCE: Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 14 The home is a Convent and met the expectations of the Sisters for Religious and Convent life. The routines of daily living were in accordance with the Sister’s expectations, preferences and capabilities. Daily life included the practices associated with Religious Life, including the daily celebration of Mass, “Offices” and Prayers. Staff understood and respected this way of life. The Sisters’ particular interests and hobbies were recorded on the care plans. One Sister spoke of her pleasure at being able to plan and work in the garden. Some Sisters were enjoyed having computer lessons. In the survey questionnaires 2 Sisters said that there were “always” suitable activities, 2 said “sometimes” and 3 said they did not need activities organised for them. Some Sisters were able to go out independently and one Sister still undertook “parish work”. Visitors were welcome in the home at any reasonable time. Sisters from the Congregation, both from the UK and overseas, were frequent visitors to the Convent. Relatives were also welcome in the home. All visitors could stay for periods in the Convent. Sisters enjoyed the local facilities, such as Towneley Park and the town centre shops. The Sisters felt that they had sufficient choice for their lives as Sisters Religious, such as the food served, hobbies and activities, and felt that staff in the home listened to their views and what they had to say. “Residents meetings” were held at the Sisters request. One of the Sisters residing in the home was the Community leader of the Convent, and she helped to ensure the Sisters’ best interests were promoted. Records viewed and the menus supplied showed that the meals served were healthy and appetising and that there was sufficient choice based on the Sisters’ preferences and special meals on “Feast days”. Records also showed that 3 full meals were served each day with the main, three - course meal served at mid - day. A lighter meal was served in the evening, but also included a cooked option for those who preferred. Sisters had the option of eating together in the dining room, where they served themselves from the table, or in the privacy of their own rooms. Appropriate assistance was given to those who needed it and food was suitably prepared for those requiring a “soft” diet. Sisters spoken with, and those who completed the comment cards, stated that they enjoyed the food whilst recognising that “you can’t please everyone all the time”. Franciscan Convent DS0000009534.V332883.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 excellent. This judgement has been made using available evidence including a visit to this service. The Sisters and visitors had appropriate channels, including a complaints procedure, through which to air any concerns or complaints. Sisters were confident that their concerns would be addressed. The Sisters were protected from abuse and felt safe living in the home. EVIDENCE: The home had a complaints procedure, which complied with legal requirements and which was accessible to the Sisters and visitors. In addition Sisters would voice their concerns to the manager and various members of the Congregation, including the Convent Community Leader. Since the previous inspection no complaints had been made, and the Sisters spoken with, and those who completed the questionnaire survey stated that they knew who to speak to if they were not happy with something and knew how to make a complaint. One Sister in conversation said she was “quite satisfied with everything”. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 16 There were policies and procedures to protect the Sisters from abuse. At previous inspections it was established that the Franciscan Convent had an “Adult Protection” policy that included a “Whistle Blowing” policy. The home also had suitable procedures that had been developed in accordance with the local “No Secrets” (Department of Health) guidance. There was also a policy on dealing with “challenging behaviour”. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 17 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, 20, 23, 24 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Convent was clean, well – maintained, comfortable and decorated, and provided a high quality environment. Communal and private space provided a peaceful spacious environment well suited to the needs of Sisters from a Religious Order who need care and support. The laundry procedures and facilities ensured a good standard of hygiene. EVIDENCE: Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 18 The Convent is an older building in the centre of Burnley, which has been adapted for its current purpose as a care home. As such it is entirely suitable for the accommodation of Sisters of a Religious Order who need varying degrees of care and assistance. There was a programme of maintenance and renewal, and the premises were well maintained and decorated. Some improvements had been made since the previous inspection. Areas of the home had been decorated as needed, some restoration to the outside brickwork and paintwork had been undertaken and a new day room had been made on the first floor from 2 bedrooms. This provided a peaceful area for Sisters who preferred not to use the lounge and dining room on the ground floor. A “walk in” bath had been installed for the use of one of the Sisters. There were small gardens to the rear and side, which were enclosed and safe, and accessible to Sisters using wheelchairs. The gardens were well kept in the growing seasons and the Sisters took pleasure from these areas. Some Sisters enjoyed working in them. The home was comfortable with a peaceful ambience. The home complied with the fire safety regulations and had a fire safety inspection last year. The recommendations of this inspection had been implemented and more automatic closure devices had been installed on doors that needed to be repeatedly kept open. There was a considerable amount of communal space consisted of a large dining room / lounge, TV lounge, library, a small lounge to receive visitors, a conservatory, a sitting area between the kitchen area and the conservatory and the chapel which was always open. There was also a small lounge, a new “day room” and kitchenette on the first floor. This allowed the Sisters a choice of shared and private areas. The private bedrooms seen met the needs of the Sisters, with personal possessions such as books, computers and music players. Furnishings in all areas were of good quality and the decorating was of a high standard. All areas of the home were clean and fresh at the time of the site visit and the Sisters stated that the home was always kept clean. The laundry facilities were of a high standard and there were appropriate laundry procedures and procedures for the control of infection. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 19 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 excellent. This judgement has been made using available evidence including a visit to this service. There were enough staff on duty, with the right kind of skills and training to meet the needs of the Sisters. The staffing compliment was supported by thorough recruitment procedures that helped to ensure only suitable staff were employed. EVIDENCE: The inspection methods used, including the number of staff on duty at the time of the inspection, the rotas supplied and discussion with the Sisters, confirmed that the Convent had enough staff on duty to meet the needs of the Sisters and to provide a high standard of care. It was clear that the staff had time to spend talking to the Sisters. Staff had a range of skills and qualifications and some staff had undertaken courses on looking after people with dementia. The PIQ and records kept in the home showed that eighty percent of care staff was trained to at least NVQ level two. There were also enough cook and domestic hours worked to ensure high standards of food served, and cleanliness in the home, were maintained. The Convent was following thorough recruitment procedures that complied with the legal requirements. This helped to ensure that only suitable people Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 20 were employed in the home. All the required Criminal Record Bureau (CRB) disclosures and written references, had been completed prior to staff commencing work in the home The PIQ, staff training records and discussions showed that staff were trained and competent to do their job effectively. The staff induction programme for staff without NVQ training was being developed according to the Skills For Care specifications. Staff had attended a variety of courses ranging from dementia care, bereavement, first aid, health and safety, fire safety, adult safeguarding, challenging behaviour and food hygiene. There was a rolling programme of moving and handling training to ensure that staff and Sisters were as safe as possible. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager was competent and qualified to run the home in the best interests of the Sisters, whose views were listened to and taken into account. The health and safety of the Sisters and staff were promoted by the homes policies and procedures. EVIDENCE: Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 22 The Registered Manager, Mrs Janet Crawford had managed the home since December 2005. She had worked as the senior assistant manager in the home for a number of years and was qualified, competent and experienced to run the home. Mrs Crawford had completed all the necessary NVQ level 4 courses, including the Registered Managers Award, and other courses relevant to her position. There was a senior assistant manager, also with the Registered Managers Award, and 5 assistant managers. Some of these members of staff and the care staff had been in post for a number of years, which helped to ensure continuity of care and stability for the Sisters. There were clear lines of responsibility and accountability within the home, and within the Congregation. The Congregational Leader, and Responsible Individual, Sister Joan O’Gorman, and the Congregational Bursar, visited the home regularly and supported the manager and the Sisters. This system ensured that the care home ran as a Convent and home of the Sisters, in keeping with their expectations and wishes. The home had a service quality monitoring policy and procedures that ensured an annual quality review be carried out. The Sisters and the staff had recently completed service quality questionnaires. These were analysed and any issues were addressed at staff meetings and Sisters’ meetings. The health and safety of staff and the Sisters was promoted. The Convent employed a Health and Safety consultant to assist with the development of policies and procedures and to ensure specialist advice. A fire safety inspection had been undertaken early in 2006, and some recommendations had been implemented. The fire safety precautions were satisfactory, the fire equipment appropriately tested and maintained, and there was a suitable fire risk assessment. To enhance fire safety additional automatic closure devices had been fitted to fire doors, that Sisters requested be kept open. However the names of the staff attending fire drills had not been recorded so it was not clear who had attended and who needed to attend. The gas and electrical installations and portable electrical appliances had current certificates of testing. There was a person competent in first aid on every shift. The staff training programme included a rolling programme of moving and handling training to help protect Sisters and staff from injury. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 23 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 (2) Requirement The medication dose given must be the same as the instructions on the Medication Administration Record (MAR), and the medication labels, unless there are supporting instructions from the prescriber. Timescale for action 12/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP8 OP9 Good Practice Recommendations It is recommended that details of visits of the Sisters to the Convent as part of the admission procedures be documented. Foot - rests on wheelchairs should always be used to protect Sisters from injury, unless there is a written risk assessment to demonstrate that it is safer to use without. The criteria or circumstances that determine which dose to administer for “variable dose” medication should be written down with the medication administration record sheet. DS0000009534.V332883.R01.S.doc Version 5.2 Page 25 Franciscan Convent 4 OP9 5 OP38 The medication administration record sheets (MARs) should be an accurate record of the medication being prescribed and administered, and medication not being prescribed and administered should not be listed on the MARs. It is recommended that the names of the staff attending fire drills be recorded. Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Franciscan Convent DS0000009534.V332883.R01.S.doc Version 5.2 Page 27 - 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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