CARE HOMES FOR OLDER PEOPLE
Franciscan Convent Residential Home 2 Broad Road Bocking Braintree Essex CM7 9RS Lead Inspector
Kathryn Moss Unannounced Inspection 22nd November 2007 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 Franciscan Convent Residential Home DS0000017822.V355353.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 Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Franciscan Convent Residential Home Address 2 Broad Road Bocking Braintree Essex CM7 9RS 01376 326654 01376 340401 franciscan@braintree43.fsnet.co.uk 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) The Missionary Franciscan Sisters Mrs Mary F McGrath Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (12) of places Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. Dementia - Code DE. The maximum number of service users who can be accommodated is: 12 10th February 2004 2. Date of last inspection Brief Description of the Service: The Franciscan Convent Residential Home forms part of large, two-storey listed building situated close to Bocking village and Braintree town. The home is owned by the Order of Missionary Franciscan Sisters and part of the building forms the Franciscan Convent, although some Sisters from the Convent are resident within the home. Premises are spacious, and there are extensive landscaped and well-maintained grounds. The home also has the use of the Chapel belonging to the Franciscan Convent, which forms part of the building. The building has been completely refurbished over the last three years, during which time the residents were temporarily accommodated in neighbouring premises that were registered for the purpose. The refurbishment was finished earlier this year, and the residents and Sisters moved back into the original home in July 2007. The conditions of registration were changed at this time, and the home is now registered to accommodate for up to 12 older people, including people who may suffer with dementia. The building has been adapted to meet the needs of people with limited mobility. The registered manager is Mary McGrath. Information on the home is available in the home’s Service User Guide, a copy of which is available in the hallway of the home. The home’s current fees range from £550 - £650. Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection visit took place on the 22nd November, lasting seven and a half hours. The inspection process included: discussion with the registered manager and responsible individual; inspection of a sample of staff and residents’ records; discussion with four staff members and with one resident, and brief conversations with some other residents. Feedback surveys were also received from three service users, three staff and one relative. Inspection reports also draw on any other information relating to a service that has been received by the CSCI since the service’s last inspection (e.g. complaints, protection of vulnerable adult referrals, Annual Quality Assurance Assessments, responses to previous reports, etc.). Outcomes relating to 25 Standards were inspected: there were 2 requirements resulting from this inspection, and 7 good practice recommendations have been made. What the service does well: What has improved since the last inspection?
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 6 The major change in the home since the last inspection has been the move back to the original premises, which have now been extensively refurbished. This has provided an enormous improvement in the facilities available to residents, including bedrooms that have been completely re-furnished and redecorated, and which are now all equipped with ensuite shower facilities. Moving residents into a new environment took considerable preparation by the manager and staff, and appeared to have been carried out with minimal disruption to residents. The home is commended on this, and during this inspection residents appeared relaxed and settled in their new environment. 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 Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 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 Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3; Standard 6 is not applicable at this home. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. Prospective residents benefit from receiving sufficient information to enable them to make an informed choice about where to live. The home’s assessment process ensures that they can be confidant that the home will meet their needs. EVIDENCE: The home’s Service User Guide is available in the hallway of the home, and has been updated to reflect the changes in the home since moving back to the refurbished premises. The Guide states that a large print version is available in the office. All three service users who completed feedback surveys as part of this inspection felt that they had been given sufficient information to make the decision to move into the home, and all confirmed that they had received a contract.
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 9 The files of three new service users were viewed, and all three contained evidence that the home had met with them and assessed their needs prior to coming to live in the home. The pre-admission assessment form covered relevant issues, including the person’s interests and any religious or cultural needs. In the case of a person who had been admitted to the home in an emergency, the pre-admission assessment form had not been fully completed, and no additional assessment information had been recorded since their admission. Residents seen appeared content and well cared for. Those spoken to or who provided feedback through surveys reported that they ‘always’ or ‘usually’ received the care and support they needed, and a relative also felt that staff gave their relative the support and care that they expected. Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. The home’s care plans enable residents to be confidant that staff understand their needs. Residents’ health and personal care needs are fully met, and care practices ensure that people’s privacy and dignity are upheld. EVIDENCE: A sample of service users’ care files viewed during the inspection were in a consistent and orderly format, which made them easy to read and to find information in. There were clear sections for: pre-admission assessments; health related records (including contact with healthcare professionals, and health related assessments such as nutrition and pressure areas); care plans; and specific assessments (e.g. moving and handling, continence, risk assessments, self-medication, etc.). Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 11 Five files were viewed, for a mixture of new and existing residents. Those for existing residents contained a good ‘history’ and an assessment of ‘daily routines and preferences’, providing a basis for identifying what support the person needed. The files of new residents did not contain these forms, and in the case of someone who had been admitted in an emergency and without a full pre-admission assessment, this meant that there was little information about the person available on their file. The manager confirmed that she had yet to complete a history and a daily routines and preferences form for the newer residents, but intended to do so. Care plans were present on all five files inspected, and most of them identified an appropriate range of issues that the person required support with; some contained good details about the action required by staff to support those needs, and it was good to see care plans reflecting the need to encourage independence, and describing what someone could do for themselves. In some cases not all support needs were fully covered: for example, two care plans relating to personal care did not show what support the person needed with bathing. Where someone had been admitted in an emergency, care plans had not yet been fully completed and the lack of other information on file meant that records did not clearly indicate the person’s needs or the support they needed. It was recognised that the person had only been in the home for a short time, but the manager was encouraged to ensure that assessments and care plans are developed promptly after admission. For existing residents, records showed that care plans had been regularly reviewed, and in one case it was good to see that care plans had been regularly added to and updated as needs changed. Where a person suffered with dementia, it was good to see that their care plans had been updated to reflect changes in staff knowledge and understanding following some training staff had attended. Health care needs appeared well met within the home: there was evidence of regular contact with health care professionals, and appropriate assessments relating to risk of pressure areas, continence, nutrition, etc. One resident reported that staff had accompanied them to a hospital appointment, which had pleased them. When asked what they felt the home did well, one relative stated that they felt the home ‘maintains the service user’s physical well being’. Residents reported that staff were ‘helpful and kind’, and that they responded promptly when call bells were rung. All residents’ bedrooms were on the first floor, and there was a staff room on this floor to enable night staff to be close to hand. Staff were observed to treat people respectfully, and were seen knocking on bedroom doors before they entered, and to use people’s preferred names (which were recorded in care plans). Bedrooms were all equipped with lockable drawers so that people could keep valuable possessions secure, although one person was not aware that they had this facility available in their room. Bathroom doors were fitted with appropriate locks. A ground floor communal toilet was noted to have large windows looking out onto the
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 12 gardens: although the windows were fitted with blinds, these were in a raised position and the manager should review whether these toilets afford sufficient privacy to people using them without staff support. The home has good facilities for keeping medication safe within the home, with a well-equipped medication room and appropriate secure storage facilities (including a controlled drugs cabinet). Medication is dispensed to the home in individual clearly labelled containers, and bottles of liquid medication were generally dated when opened. Issues raised at the last inspection regarding medication administration practices (re secondary dispensing into different containers) had been fully addressed by the home. Medication records included some good medication profiles for each person, although entries on some profiles were several years old, which suggested that these might not have been updated. It was good to see that three people were managing their own medication, and that that systems were in place to offer any support or monitoring required. Where relevant there was also a risk assessment completed that covered the person’s general physical and cognitive abilities, although was not specific to the task (e.g. ability to open containers, remember times and quantities of medication, keep medication secure, etc.). The pharmacist provides the home with printed Medication Administration Records (MAR) for each person, to assist the home in recording when medication is administered. At the last inspection, medication received by the home was not being clearly recorded, and it was good to see that this was now being recorded on the MAR. In one case details of medication handwritten on the MAR showed that quantities of medication had been carried over from the previous month, but the amount brought forward had not been recorded. Records of medication administered were generally well maintained, with no gaps seen in the record; where a recording error had been made, this was clearly explained on the reverse of the MAR. There were a few recording issues that should be addressed by the home to promote good practice. For example: prescribed ointments were sometimes ticked for when applied, but not actually signed for; one prescribed ointment had for a while been applied more frequently than the instructions directed, with no evidence that the GP had advised this or been consulted; there were variations in recording practices when ‘as required’ medication was not needed (sometimes leaving a blank space on the MAR, sometimes entering a code for non-administration); and codes for reasons for non-administration were not always clearly defined. At the last inspection it was noted that all senior staff had attended training in medication administration. The manager stated that senior staff have subsequently completed some further internal training this year using a DVD training pack; however, there is no formal system for assessing staff competency in medication administration, and this should be developed. The manager was in the process of developing and introducing a form on which to record regular audit checks on medication stocks. Franciscan Convent Residential Home DS0000017822.V355353.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 and 15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. The home provides flexible routines and a lifestyle that enables residents to make choices and to engage in their individual interests. The home provides a varied and balanced diet. EVIDENCE: Some of the care records viewed contained good profiles on the person, describing their life history and interests. This was helpful information for staff, providing ideas for interaction and activities. Some files viewed also contained care plans that referred to peoples’ needs in relation to social interaction and activities. The home does not currently have a formal activities programme, but feedback from residents indicated that activities were available to them. One person consulted did not wish for any organised activities; another expressed some disappointment that there were not more people in the home who they could sit and chat to. Activities were discussed with the manager and staff,
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 14 and it was noted that the needs of people currently living in the home are such that it is quite difficult to organise formal activities: some residents are not able to easily participate in group activities, and others prefer to occupy their own time and not to join in with activities. A volunteer still visits the home each week, but few residents are able or wishing to engage in the craftwork that the volunteer previously organised. It was noted that many people benefited more from one-to one time spent with them. A staff member who provided feedback confirmed that staff did spend time with individuals, stating that “as we are a small home, time is spent with residents chatting or watching a program on TV and chatting about it, chatting about their lives, families, pets, etc.” It was good to see that a resource to encourage stimulation had been developed for one person (a ‘rummage basket’), and had been positively responded to. However, one-to-one interaction with people was often not recorded, making it difficult for the home to evidence how much social activity was taking place. The manager was aware that this was an area where the home needed to develop, and the Annual Quality Assurance Assessment completed by the home identified that the home could improve ways of involving people who suffered with dementia in activities. It was good to see that one person chose to help with some household tasks in the home, and was able to do this. The manager also stated that staff can be made available to take residents out if they wish, and confirmed that two residents had been out on a trip the previous week. Where people chose to spend a lot of time in their own rooms, it was good to see that rooms were well personalised and equipped with their personal items (e.g. televisions). A hairdresser regularly visits the home, and the refurbished premises includes a suitably equipped room where people can have their hair done. A daily mass is held in the chapel, which some residents attend, and the home arranges for ministers of other faiths to visit residents where requested. Residents can receive visitors at any time, and the home has a room available to visitors: it was good to see that one person had a regular visitor who was able to stay overnight in the home. There are therefore a variety of ways in which the lifestyle offered by the home meets peoples’ social and religious needs. Meals observed on the day of the inspection smelt and looked appetising. The home does not have set menus, but the cook decides on the meals from day to day. A clear record is maintained of all meals served, which showed a good range of balanced meals and enables the cooks to monitor that there is variety. A choice of food is available at both lunch time and tea time, and it was good to see that residents do not have to chose what they want until the time of the meal. A cook spoken to was aware of individual likes and dislikes and stated that they base menus around this: although they do not directly consult with residents each week about the menu, they try to accommodate individual requests. The cook showed appropriate knowledge of any dietary needs (e.g. diabetics). Feedback from residents, through surveys and discussion on the inspection, was generally positive about the meals provided. Franciscan Convent Residential Home DS0000017822.V355353.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 and 18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. Practices in the home safeguard residents, and ensure that concerns are listened to and addressed. EVIDENCE: The CSCI has not received any complaints in the last year about the home, and records viewed on the inspection showed that the home had also not received any formal complaints. More minor issues or concerns raised by residents or relatives are not routinely recorded, and the manager was encouraged to record all concerns that the home has addressed, as well as more formal complaints. The home’s complaints procedure was noted to be readily available in the hallway, and a relative who provided feedback confirmed that they were aware of the home’s complaints procedure. A resident who was interviewed confirmed that they could speak to the manager if they had any concerns, and felt able to do so, and other residents who completed feedback questionnaires were all aware of how to make a complaint if they needed to. The Annual Quality Assurance Assessment submitted by the home confirmed that the home has policies and procedures covering safeguarding adults and the prevention of abuse (including Whistle Blowing), and that these had been
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 16 reviewed this year. These policies were not viewed on this inspection. Most staff had received training in the Protection of Vulnerable Adults (POVA), although this was now a couple of years ago; for just a few staff there was no evidence that they had attended POVA training. The manager was aware that POVA training needed updating, and was advised that even part-time staff must receive training on this subject. New staff cover POVA issues as part of a two-day induction course that that they attend, and evidence of this induction was seen on a new staff member’s file. The manager confirmed that this is also discussed with new staff, and is a subject that would be discussed in supervisions or staff meetings if the need arose. There have been no POVA concerns raised in the home since the last inspection. All three staff who completed feedback surveys as part of this inspection confirmed that they knew what to do if a service user or relative raised any concerns about he service. Franciscan Convent Residential Home DS0000017822.V355353.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, 22, 24 and 26 People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. Refurbishments to the home ensure that residents are provided with a high quality of accommodation, in a safe, well-maintained, clean and hygienic environment. EVIDENCE: The home only moved back into the original, refurbished premises in July 2007: it is therefore newly decorated and furnished, and has predominantly new equipment throughout (e.g. fire alarm system, call system, passenger lift, heating, etc.). The premises have been re-designed and refurbished to a high standard, whilst retaining the period and listed features of the home. Bedrooms are light and airy, and all provide sufficient space for a range of
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 18 furniture. Rooms all have new furniture (except where residents have chosen to bring in their own), including fully adjustable beds. All bedrooms have ensuite toilet and shower facilities, and there is a separate assisted bathroom in the home. There is one communal lounge overlooking the gardens, and a separate dining area with an adjacent courtyard area. A small room on the first floor, used for hairdressing and visiting professionals (e.g. chiropodist), has comfortable seating and can also be used by service users and their visitors; there is also a room for any visitors who wish to stay overnight. The home has extensive and very beautiful grounds: the area close to the house has been attractively landscaped, with safe footpaths and seating provided on a covered veranda area adjacent to the lounge. A staff room is available on the ground floor, with a further staff room on the first floor so that night staff are close to residents (as all bedrooms are on the first floor). The redesign of the premises has made every effort to make the building accessible to service users: although the first floor is on a number of different levels, wherever possible small ramps have been fitted to minimise mobility difficulties, and in one place a stair lift has been fitted to a small flight of steps. A fully mechanised bath is available, and toilet areas have been fitted with drop down handrails to promote independence. Although ensuite showers have slightly raised shower trays, and therefore can only be used by people who are still mobile, all are equipped with shower seats. Most people are still weightbearing, but the home does have mobile hoists available and was noted to have good storage areas for hoists and wheelchairs so that these did not present a hazard in bedrooms or corridors. The home has good arrangements for the ongoing maintenance of the property. The home employs a person responsible for maintenance and health and safety, who demonstrates good knowledge of all issues relating to the safety and maintenance of the premises. There were systems in place for staff to identify any repairs required, and to record when these have been actioned. It was good to see that work was already in progress to touch up minor paintwork repairs. Staff training in Infection Control had been arranged for the week following the inspection. Personal protective equipment (disposable gloves and aprons) was available to staff to promote good infection control practices. All service users consulted as part of this inspection confirmed that the home is always kept clean and fresh. The home has a large and well-equipped laundry area, including two dryers and three washing machines, all with sluice/73°C wash cycles that meet infection control standards. Red bags were used to transfer soiled laundry into the washing machines, in order to minimise risk of cross contamination. The laundry person showed good awareness of infection control procedures, and was due to attend infection control training that was taking place in the home the following week. Franciscan Convent Residential Home DS0000017822.V355353.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 and 30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. The home provides staff in sufficient numbers, and with suitable skills and experience, to ensure that residents’ needs are met. Residents are protected through the home’s recruitment. EVIDENCE: Staffing levels were discussed with the manager and staff, who felt that current staffing levels met the needs of the people living in the home at this time. All three service users who completed surveys stated that there were always staff around when they needed them, and a person interviewed during the inspection said that staff came promptly when they pressed their call buzzer. Staffing was provided flexibly during the day, with three staff on duty at times when residents most needed assistance, and two on at other times (with one waking and one sleep-in at night). The manager stated that extra staffing can be arranged if there is a particular need (e.g. if a resident wishes to be taken out during the day). The home currently employs 15 care staff, plus 3 bank carers. Recruitment records were viewed for two new staff, and demonstrated that the home’s recruitment practices satisfactorily protected residents. All appropriate checks
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 20 had been carried out prior to the person starting work, and records included evidence of employment history, medical questionnaires, declarations of criminal record, and evidence of ID. The files did not contain photos of each person, other than on copies of passports. Both files contained two written references, although in one instance a last employer reference did not appear to have been sought. Files contained evidence that a POVAfirst had been received before starting, with a Criminal Records Bureau (CRB) check received subsequently; the Annual Quality Assurance Assessment (AQAA) completed by the manager confirmed that staff employed on just a POVAfirst check are supervised until the enhanced CRB is received. New staff files contained evidence of previous training (where available), and also evidence of their induction at the Franciscan Convent. A comprehensive initial induction checklist had been completed when new staff joined the home, and it was good to see that both staff were in the process of completing an induction based on the Skills for Care ‘Common Induction Standards’. One person had been appropriately inducted in their last employment in the care sector, and was therefore only completing the relevant sections of the Common Induction Standards. The other person had completed a two-day induction course when they joined the home, covering all core training. Of the 15 permanent staff working in the home, seven have achieved NVQ level 2 or 3 and three are qualified nurses (therefore ten staff are appropriately qualified); a further two are enrolled to begin NVQ level 2 in the New Year, and three staff who already have NVQ level 2 are due to start NVQ level 3. Two of the bank staff also have an appropriate qualification (the third is undergoing training), and the cook has achieved NVQ level 2 in catering. This is a good level of qualification amongst the staff in the home. The home generally provides a good level of core training for staff. The home maintains individual staff training profiles, which showed training completed by staff this year as including: fire safety, moving and handling, medication administration, dementia care, and health and safety. Training in infection control was booked, and it was good to see that the home regularly updates moving and handling training, with further training in this booked for the New Year. Whilst most staff training profiles showed that they had completed all core training, there were one or two staff profiles that showed very little evidence of training: these were part time staff, and it was noted that the home’s AQAA identified that the home could do better at ‘encouraging all staff who have contact with the residents to be involved in all training’. As noted in an earlier section, POVA training had not been provided for several years and needed updating. It was good to see that staff had attended further dementia care training this year, and the manager was able to describe how this training had positively affected practices in the home. The home did not have a central summary of all staff training, to assist in monitoring and planning training. Franciscan Convent Residential Home DS0000017822.V355353.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, 35 and 38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of available evidence, including a visit to this service. The home is well-managed, and residents benefit from the knowledge and experience of the registered manager. The home is run in the best interests of residents, and health and safety practices protect staff and residents. EVIDENCE: The registered manager is experienced and competent: she is a qualified nurse and has completed the Registered Manager’s Award (NVQ level 4 in Management), as also attends other training to update her skills and knowledge. Staff and residents spoken to were all positive about the manager, finding her supportive and approachable. One staff member who provided
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 22 feedback stated that they enjoyed working at the home, and felt that ‘the home is managed really well’. A representative of the registered provider carries out regular monitoring visits to the home, to check on aspects of management and practice and to speak with staff and service users. The home has a survey form that had recently been distributed to residents to seek their feedback on the home: the manager stated that only one completed survey had been returned, and discussed the fact that many people currently living in the home have difficulty completing a written questionnaire, making it hard to get independent feedback from them. Good informal monitoring takes place through the manager regularly talking to residents, but little of this is currently recorded. A survey form had also been used to seek feedback from people attending the home for respite during the year: although some responses had been received, these had not been formally evaluated and summarised. The home does not have a current annual development plan, although it was acknowledged that this year the home had been focusing on successfully moving residents back into the refurbished premises, which had been a major initiative and been the focus for much of the planning and action in the home this year. The manager had completed an Annual Quality Assurance Assessment (AQAA) for the CSCI, which demonstrated an ability to evaluate the service and to identify areas for improvement. The home maintains evidence of regular health and safety checks on rooms, carried out monthly by the maintenance person. Other checks carried out by the manager (e.g. checks on care plans and medication administration records) are not currently recorded, and the manager had identified that one of the areas the home could improve on is recording practices relating to monitoring practices in the home (e.g. feedback about quality of care, activities records, monitoring of medication records, etc.). The home does not look after money on behalf of residents: any items that people want are purchased by the home, and itemised on a monthly invoice received by residents or their relatives. Records of money spent on residents’ behalf were not viewed on this inspection. All rooms have lockable storage facilities to enable people to keep their own money secure. The home has a clear Health and Safety policy and procedure, and most staff had attended relevant health and safety training (see previous section). The home has effective systems in place for ensuring the safety of the premises and equipment: the maintenance person completes monthly health and safety room checks, and maintains clear records of the servicing of utilities and equipment, and of regular internal checks carried out on facilities and equipment (e.g. hot water tap temperatures, checks on electrical equipment, etc.). There was also evidence of the regular testing of fire alarms and emergency lighting, checks on fire equipment, and monthly fire drills. The home had recently commissioned a comprehensive fire risk assessment, which
Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 23 included an action plan: the maintenance person had done extensive work to action all the recommendations raised, and is commended on this. The maintenance person was in the process of revising the home’s fire procedure/ policy, and the home was planning to obtain a fire evacuation chair. Accident records were not inspected on this occasion; the home has not reported any injuries to residents caused by falls over the last year. Risk assessments for safe working practices had mostly been reviewed earlier in the year, but had not been reviewed since the move back to the refurbished premises: some therefore did not fully reflect some of the working areas and risks in the current home, and need to be reviewed. The home’s policies and procedures were not specifically inspected on this visit. The Annual Quality Assurance Assessment (AQAA) completed by the home indicated that the home’s policies had been reviewed this year, which was good to see. However, according to the AQAA there were some policies and procedures that the home did not appear to have in place: where appropriate to the needs of the home, these should be developed (e.g. dealing with violence and aggression, annual development plan, code of conduct, referral and admission, recruitment, values of privacy and dignity, etc.). Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 24 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X 3 X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 25 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 OP30 Regulation 18 Requirement To ensure the protection of residents, all staff working in the home must attend training in core subjects (e.g. moving and handling, fire safety, POVA, etc). To ensure the safety of staff and residents, risk assessments on safe working practices must be completed for the refurbished premises. Timescale for action 29/02/08 2 OP38 13(4) 31/01/08 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 Refer to Standard OP5 OP7 Good Practice Recommendations Where people are admitted to the home in an emergency, the manager should ensure that their needs are fully assessed within 5 working days (reference Standard 3). It is recommended that staff ensure that care plans cover all areas of daily living where a person requires support, and identify the action required by staff. Care plans should be developed as soon as possible after a person comes to live in the home.
DS0000017822.V355353.R01.S.doc Version 5.2 Page 26 Franciscan Convent Residential Home 3 OP9 It is recommended that the home ensure that medication recording practices are consistent, and that records are regularly monitored to identify any recording issues. As part of staff training, the home should develop systems for assessing and recording staff competence in medication administration. Where individuals wish to self-medicate, risk assessments used should specifically assess the different aspects of the task, any risks involved, and any preventative measures in place. It is recommended that medication profiles be regularly reviewed and up-dates when medications change. The home should continue to explore ways of offering opportunities for activity and occupation suitable to the needs of each individual living in the home, and to develop ways of evidencing the activity and interaction taking place. The home should ensure that POVA training is regularly updated for all staff. When new staff are recruited, the manager must ensure that last employer references are always sought (where available), and that files include a photo of the staff member. Quality assurance processes need some further development within the home, including ways of obtaining feedback from residents and other stakeholders (relatives, healthcare professionals, etc.), annual development plans, records to evidence the self-monitoring of practices within the home (i.e. internal auditing procedures), and the development of policies and procedures. 4 OP12 5 6 OP18 OP27 7 OP33 Franciscan Convent Residential Home DS0000017822.V355353.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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
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