Inspection on 08/11/05 for Franciscan Convent

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Franciscan Convent 16/04/07

Franciscan Convent 15/03/06

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 Unannounced Inspection 8th November 2005 11:45 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.V264577.R01.S.doc Version 5.0 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.V264577.R01.S.doc Version 5.0 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 0161 7946420 Franciscan Missionaries of St Joseph Sister Anne Pilling 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.V264577.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2005 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 needing care from this Order have been offered accommodation; there are no lay people in the home. The Roman Catholic faith underpins the life of the home. Most of the routines are those of Convent life that the Sisters have been familiar with throughout their religious lives, including the daily celebration of Mass and Prayers 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 22 bedrooms, which at the occupancy levels at the time of the inspection, were all used as single rooms. There were 10 WCs, 4 baths, two 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 and T.V. lounge. The Chapel was always open. A wide range of policies and procedures, which complied with the Care Home’s Regulations 2001 and the National Minimum Standards, underpinned the high quality of care provided in the home. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection, the purpose of which was to assess important areas of life in the home that should be inspected over a 12 month period, check the progress of previous legal requirements and good practice recommendations, and check any other matters in the home which came to the inspector’s notice. The inspection took 6 hours and comprised of, talking to the Sisters, a tour of the premises, looking at Sisters’ care records and other documents, and discussion with the manager, Sister Ann Pilling and Senior Assistant Manager, Janet Crawford. Five Sisters and two other members of staff were spoken with. 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. 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. The home was well maintained and decorated and provided a comfortable environment for the retired Sisters. There have consistently been sufficient members of staff on duty, with sufficient skills, to meet the needs of the Sisters. The home has benefited from a stable long serving management team, lead by Sister Anne Pilling, which has helped to ensure consistent high quality care. Sister Anne had many years nursing and management experience both in the UK and overseas, as a member of the Franciscan Missionaries of St Joseph, and ensured that the care home was run as the Convent home of the Sisters, in keeping with their expectations and wishes. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 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 Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 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, 3, 4 & 5 The Convent’s admission procedures, including admission assessments, were appropriate for Sisters as members of a Religious Order, and for their expectations as older Sisters needing care. The procedures helped to make sure that the home could meet the Sisters’ needs. EVIDENCE: The Statement of Purpose and the Service User Guide had been reviewed and updated, and copies had been supplied to the CSCI. These documents were in accordance with legal requirements and standard 1. Retired Sisters of the Order of the Franciscan Missionaries of St Joseph, who need care, are admitted to the Convent. As one Sister said, “this is our home”, and is another part of Convent life as a Sister Religious. The admission procedures are therefore in keeping with this situation. These procedures take into account the wishes of the Sisters, the guidance of the Congregational Leader (“The Registered Person”) and whether or not the Burnley Convent can meet the Sisters’ care needs. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 9 The written assessments of the Sisters’ care needs were comprehensive and contained all matters listed in standard 3.3. Those documents viewed were well completed, in sufficient detail and with good risk assessments, including risk of falling and risk of pressure sores. Those Sisters with a diagnosis of dementia had a “mental health” assessment. Some Sisters were admitted for a trial period to help ensure that the Convent could meet their needs. The Sisters had wide ranging 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. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 10 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, 8, 9 & 10 The care plans were detailed and well written, and contained useful 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. Some medication systems and practices must be improved to ensure safe administration. The values of respecting privacy and dignity underpinned the care in the Convent and were upheld. EVIDENCE: All the Sisters had care plans. Those viewed were well written, and in sufficient detail. They contained useful information on all aspects of the Sisters’ health, personal and social care needs listed in 3.3. Moving and handling assessments had been undertaken. Relevant risk assessments had been undertaken, including vulnerability to pressure areas. The intervention and preventative measures for pressure areas, was recorded on the care plans, and appropriate assistance and equipment was given from the District Nurses. 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. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 11 The care plans were being reviewed, at least monthly, and those Sisters who wished to be, were involved in this. 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 that needed assistance. All visits made by GPs, nurses and other professionals were recorded. There were areas of good practice in relation to medication administration including detailed and wide - ranging policies and procedures and staff checking the prescriptions prior to dispensing. All staff administering medication had undertaken accredited training. However some aspects of the medication system, and procedures, must be improved to ensure all medication is administered accurately and safely. All medication administered must be recorded. Staff must only administer medication that has been prescribed, including lactulose. When doses are altered there must be clear instructions, criteria and information on the MAR sheets. The criteria for “when required” (PRN) medication must be clearly defined and recorded on or near the MAR sheet. All Controlled Drugs (CD’s), including Temazepam, should be stored in the home’s CD cabinet. The values of privacy and dignity underpin the care provided in the Convent. Sisters stated that members of staff showed a good understanding of the importance of respecting privacy and dignity. They showed sensitivity to the Sister’s individual needs and the circumstances of their religious life including respect for the work of the Sisters in the different locations around the world. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 12 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, 13 & 14 The lifestyle in the Convent matches the Sisters’ expectations, and enables them to continue in the routines and practices of religious life. This includes maintaining contacts in the community, contact with relatives and members of the Congregation. The Sisters have an appropriate level of control and choice over their lives, in accordance with their expectations as members of a Religious Order. EVIDENCE: Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 13 The home is a Convent and meets 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. Sisters continued with the familiar routines and practices associated with their religious life, including the daily celebration of Mass, “Offices” and Prayers. 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 enjoying having computer lessons. 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 spoken with stated that they had a level of choice in their lives that was in keeping with their religious life, and the Vow of Obedience, with some of the choices that are important to lay people not necessarily being as important to themselves as Sisters Religious. One of the Sisters residing in the home was the Superior of the Convent, and she helps to ensure the Sisters’ best interests are promoted. The Sisters live under a Vow of Poverty, and The Congregation provides for the Sisters’ entire needs for clothing and daily living. The only personal money they have is a small personal allowance provided monthly by the Congregation. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 14 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): 16 The Sisters had appropriate channels through which to air any concerns or complaints, and were satisfied that these would be dealt with appropriately. Relatives and visitors also had access to the Convents’ complaints procedure. EVIDENCE: The home had a complaints procedure, which complied with legal requirements. The Statement of Purpose and the Service User Guide included a summary of this. In reality if they had concerns, Sisters would speak to various members of the Congregation, including the Superior of the Convent or the Congregational Leader. Since the previous inspection one complaint had been made to the CSCI by relatives, about the way one of the Sisters had been transferred to another care home in Liverpool. The CSCI passed the complaint to the Congregational leader for investigation. The CSCI concluded that the complaint was appropriately and thoroughly investigated and that part of it was upheld. The Sister had been transferred without a comprehensive assessment of her needs having been undertaken by the care home to which she was admitted Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 15 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 & 26 The Convent was clean, well - maintained and decorated, and provided an environment well suited to the needs of Sisters from a Religious Order who need care and support. EVIDENCE: Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 16 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. The home was clean, warm and comfortable with a peaceful ambience. 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 registered provider must ensure that all the fire doors comply with the fire regulations. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 17 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 & 29 There were enough staff on duty, with the right kind of skills, 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 Convent had enough staff on duty to meet the needs of the Sisters. This was confirmed at the time of the inspection by the number of staff on duty and through talking to the Sisters and the staff. Members of staff spoken with stated that they felt they were able to spend “quality time” with the Sisters. There were staff with a range of skills and qualifications and some staff had undertaken courses on looking after people with dementia. The Convent was following thorough recruitment procedures that complied with the legal requirements. This helped to ensure that only suitable staff were employed in the home. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 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 & 32 The registered manager, Sister Anne, was qualified, experienced and competent to run the home, and had ensured high standards were maintained throughout. The home was also run in such a manner as to meet the expectations and wishes of the Sisters as members of the Religious Order. EVIDENCE: Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 19 Sister Anne, the registered manager, was qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Sister Anne is a Registered General Nurse and has managed the home since March 2000. She had completed all the necessary NVQ level 4 courses, and had extensive nursing and management experience in the Order of the Franciscan Missionaries of St Joseph, both in the UK and overseas. She had also completed other relevant courses. There was a senior assistant manager and 3 assistant managers. The senior assistant manager, who has acted as Deputy Manager, has gained her NVQ level 4 in management, and almost completed the “Registered Managers’ Award”. These senior members of staff had all been in post for a number of years and presented as a stable and cohesive team. There appeared to be clear lines of responsibility and accountability within the home, and within the Congregation, of which Sister Anne is part. The Congregational Leader, Sister Joan O’Gorman, was the registered person, and in this capacity, conducted monthly visits to the home. Sister Anne has ensured that the care home has been run as the Convent home of the Sisters, in keeping with their expectations and wishes. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 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 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 2 X X X X X X 3 STAFFING Standard No Score 27 4 28 X 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X x Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 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. 1 Standard OP9 Regulation 13 (2) Requirement The criteria for the administration of all “when required” and “variable dose” medication must be clearly defined and recorded on or near the MAR sheets. Records must show the quantity of medication administered All medication administered must be recorded. Staff must only administer medication that has been prescribed, including lactulose. When doses are altered there must be clear instructions, criteria and information on the MAR sheets. The registered provider must ensure that all the fire doors comply with the fire regulations Timescale for action 03/12/05 2 3 4 OP9 OP9 OP9 13 (2) 13 (2) 13 (2) 08/11/05 08/11/05 08/11/05 5 OP19 23(4)(c) (v) 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 22 No. 1 Refer to Standard OP9 Good Practice Recommendations All Controlled Drugs (CD’s) should be stored in the home’s CD cabinet. Franciscan Convent DS0000009534.V264577.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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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