Inspection on 01/02/06 for Holy Cross Priory

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holy Cross Priory 11/11/08

Holy Cross Priory 21/11/06

Holy Cross Priory 22/08/05

Holy Cross Priory 07/01/05

Holy Cross Priory 27/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Holy Cross Priory Cross-in-Hand Heathfield East Sussex TN21 0TS Lead Inspector Niki Palmer Unannounced Inspection 1st February 2006 08:50 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 Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holy Cross Priory Address Cross-in-Hand Heathfield East Sussex TN21 0TS 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) 01435 863298 The Grace and Compassion Benedictines Sister Jacintha Aruldass Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only older people will be accommodated. Residents must be aged sixty five (65) years or over on admission That no more that thirty (30) residents are accommodated Date of last inspection 22nd August 2005 Brief Description of the Service: Holy Cross Priory is a residential home registered to provide care and accommodation for up to thirty older people. The home has been owned and run by the Benedictine Sisters of our lady of Grace and Compassion, a registered charity since 1964. The Charity is the registered owner of a further six residential/nursing homes and several sheltered housing schemes nationally. The home is a large detached Victorian manor house comprising of two detached properties, with part of the home registered as a nursing home. Within the grounds of the home are also sheltered accommodation units. The building has had many uses in its history including a hotel in the 1930s and as a monastery during the 1950s. It is set within extensive grounds in a rural location, between the villages of Cross-in-Hand and Blackboys. The home is presented across three floors with a shaft lift providing level access to all floors. Residents accommodation consists of twenty-nine single rooms with the majority being en-suite. Shared facilities include a large lounge, dining room, entrance hall and chapel. Care staff and residents are principally from the religious community. The homes literature states that one of its main aims is to provide the highest standard of care for every person living here at the home, their family and carers. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Holy Cross Priory will be referred to as ‘residents’. This unannounced inspection took place on Wednesday 05th February 2006 between 08.50am and 1.00pm. The inspection began with discussions with the Registered Manager and Deputy Manager of the home in respect of progress made since the last inspection. In order to gather evidence on how the home is performing, individual discussions took place with four residents, three care staff and a visiting Community Dietician. 23 residents were accommodated at the time of the inspection. Other records and documentation inspected included: three individual plans of care, the home’s medication procedures, the systems in place for handling complaints and safeguarding residents from harm, staff training records, the home’s accident book, a sample of recruitment files and the systems in place for handling residents’ monies. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 22nd August 2005. What the service does well: What has improved since the last inspection? The home’s Statement of Purpose and Service Users’ Guide have been reviewed and a great deal of work has been undertaken to improve care planning procedures. The home’s recruitment of staff is good; this helps to ensure the safety of residents. Detailed accident and incident records are now kept. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. Sufficient information is provided to all prospective residents in order to help them in their decision of where to live. EVIDENCE: The home has a detailed Statement of Purpose and Service Users’ Guide in place. Both are kept on display within the main reception area of the home for residents and visitors to see, alongside a copy of the most recent inspection report. Both the Statement of Purpose and Service Users’ Guide were found to be detailed and comprehensive covering: the home’s philosophy of care, the facilities provided, the arrangements for leaving or temporarily vacating, complaints procedure, advocacy services and health and safety aspects. Since the last inspection both documents have been dated to evidence that they have been reviewed. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Whilst the home’s care planning procedures have improved considerably, medication practices are poor and potentially place residents at risk. EVIDENCE: Three individual plans of care were seen. Since the last inspection, the home has worked tremendously hard to improve its care planning procedures. All residents now have their own individual files, which are personalised and outline all areas of daily living. Despite comprehensive assessments being in place for the prevention of falls and nutrition, the home is required to ensure that specific guidance is in place for staff to follow, for example how to reduce any potential risks and ensure that nutrition is maintained. A Community Dietician confirmed that the home make appropriate referrals via the General Practitioner and are ‘always receptive to any advice’. A recommendation has been made for the home to purchase adequate weighing scales. The home’s medicine storage and administration system was viewed. The home currently has two systems in place: Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 10 - A monitored dosage system provided by the pharmacy - Individually prescribed medicines from the GP surgery Concerns were raised during the inspection regarding the ‘potting up’ of individually prescribed medicines prior to administration. This is a ‘task focused’ procedure as opposed to ‘resident focused’. A Pharmacy Inspector will be liaising with the home to review its current procedures. Whilst medication administration records were on the whole completed, it was noted that one individual’s medication had been accidentally removed from the blister pack in error. Whilst the Deputy Manager informed the Inspector that this had been an ‘error’ on behalf of the nurse in charge, there was no record of this on the day of inspection. The home is required to ensure that all medication errors are reported and recorded in line with the home’s drug error policy and procedure. In addition, the home is required to have written criteria in place for the administration of medicines prescribed on an ‘as and when required’ basis. All residents and observations of staff’s interactions with others confirmed that that staff uphold the privacy and dignity of residents. All residents are addressed by their preferred term and are spoken with in a manner that is appropriate, kind and respectful. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14. Residents are encouraged to remain in close contact with friends and relatives and are supported to make decisions and choices in most areas of their lives. EVIDENCE: All residents spoken with confirmed that relatives and friends are always made to feel welcome to the home. They are always offered a warm drink and lunch as necessary. During the Christmas period some residents chose to stay with friends/relatives, whilst others preferred to stay at the home and partake in organised festivities such as carol singing, daily mass and entertainment provided by the Sisters and Novices. It was pleasing to note that photographs had been taken by one of the residents living within the home. Due to the rural location of the home, local amenities are not easily accessible, however a mobile library visits the home on a weekly basis and transport arranged via Age Concern supports residents to visit the nearby village on a regular basis. It was evident through speaking with residents that they are encouraged by the home to exercise choice and control over their lives as much as possible. Comments included: ‘I live my own life here’, ‘get up and go to bed whenever I like’ and ‘it’s just as if it’s my home’. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 12 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 and 18. Adequate systems are in place to ensure that all complaints are handled appropriately and that residents are safeguarded from harm. EVIDENCE: The home has a detailed complaints procedure in place, which is in the process of being updated. Through speaking with residents and the examination of records, it was apparent that very few complaints are ever made to the home. No complaints have been received by the CSCI since the last inspection. It was pleasing to note that since the last inspection external adult protection training has been provided to staff. Those spoken with were able to demonstrate a sound knowledge of what constitutes abuse, how to recognise it and the procedures that they would follow in reporting suspected abuse. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 13 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, 23 and 26. Physical standards and accommodation throughout the home are good and ensure that residents live in a comfortable, well-maintained and safe environment. EVIDENCE: A small number of bedrooms and communal areas were seen. The home has recently applied to the CSCI to reduce its numbers from 30 to 24. This will enable some of the bedrooms to be increased in size and have en-suite facilities available. All residents that will be affected have been and are in the process of being consulted in relation to their preference of room colour and shower or bathing facilities. It is anticipated that this work will commence shortly once a reliable and efficient workforce has been identified. It is anticipated that disruption to residents will be kept to a minimum. All areas were found to be clean, well-maintained and warm. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 14 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): 29 and 30. Recruitment practices and procedures have improved; this helps to ensure the safety of residents. All staff are adequately trained to meet the assessed needs of residents. EVIDENCE: Three newly appointed person’s recruitment files were seen on the day of inspection. It was pleasing to note that since the last inspection the home’s application form has been amended to allow for a detailed history of employment details to be recorded. Satisfactory written references, Criminal Record Bureau and PoVA First checks had been obtained for each person prior to employment. Good policies and procedures are also in place to ensure that all volunteers are subject to rigorous recruitment checks. A vast number of the staff team have attended various training days and sessions since the last inspection including: moving and handling, infection control, elder abuse, basic life support and bereavement. All staff spoken with said that the training opportunities are relevant and frequent at Holy Cross Priory. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 15 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): 33, 35 and 38. Although feedback from residents is sought, they are not kept informed of the results of satisfaction questionnaires. The systems in place for handling residents’ monies are poor. EVIDENCE: Residents’ questionnaires are distributed by the home on an annual basis. They are based on the National Minimum Standards and cover the following areas: choice, meeting needs, protection, staffing and the management of the home. Whilst it was pleasing to note that over 50 of questionnaires were returned and were on the whole very positive, the home has not analysed the results and made them available to residents in a format that is easy to read and understand. This is unfortunate as the outcome of the questionnaire is very positive for the home. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 16 Most residents and/or their relatives manage their own finances with the exception of three individuals. Major concerns were raised regarding the way in which the records are maintained. Some pages had been torn out of individual records, balances had not been checked and dates and signatures had not been recorded. This was discussed in detail with the Registered Manager and a requirement made. Concerns were raised during the previous inspection report regarding the homes record keeping of accidents. Good progress has been made to ensure that clear records are now kept and regularly checked by the Registered Manager. A recommendation has been made for the home to keep a record of when risk assessments have been updated following any accident or incident. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 1 X X 3 Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes. 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 OP7 Regulation 13(4)(c) Requirement Timescale for action 31/05/06 2. OP8 3. OP9 4. OP9 5. 6. OP9 OP33 7. OP35 That risk assessments for the prevention of falls provide staff with specific guidance to follow to reduce any potential risks. 14(1) That nutritional assessments 17(1)(a) provide staff with specific Sch3 guidance to follow in relation to maintaining an adequate diet. 17(1a) That the home reviews its Sch 3(k) current medication procedures with support from a Pharmacy Inspector. 17(1a) That all medication errors are Sch 3(k) reported and recorded in line with the home’s drug error policy and procedure. 17(1a) That written criteria is in place Sch 3(k for all medicines prescribed on an ‘as and when required’ basis. 24(1)(2) That the results of residents’ (3) questionnaires are analysed and made available in a format that is easy to read and understand. 17(2)Sch4 That accurate written records of (9)(a)(b) all transactions are maintained in respect of residents’ monies. 31/05/06 31/03/06 01/02/06 31/03/06 31/03/06 31/03/06 Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 19 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 OP8 OP38 Good Practice Recommendations That suitable weighing scales are purchased as recommended by the Community Dietician. That a central record is kept of when risk assessments have been updated following any accident or incident to a resident. Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holy Cross Priory DS0000021140.V278881.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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