Inspection on 22/08/05 for Holy Cross Priory

This inspection was carried out on 22nd August 2005.

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 01/02/06

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 22 August 2005 11:00 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 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 H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holy Cross Priory Address Cross-in-Hand Heathfield East Sussex TN21 0TS 01435 863298 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Trustees of the Grace & Compassion Benedictine Sister Jacintha Aruldass Care Home (CRH) 30 Category(ies) of Old age, not falling within any other category registration, with number (OP), 30 of places Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That only older people will be accommodated. 2. Residents must be aged sixty five (65) years or over on admission. 3. That no more than thirty (30) residents are accommodated. Date of last inspection 23 February 2005 Brief Description of the Service: Holy Cross Priory is a residential home registered to provide care and accommodation of 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 1930’s and as a monastery during the 1950’s. 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 ensuite. 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 H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 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 a Monday between 11am and 4pm. The inspection began with discussions with the Registered Manager of the home in respect of progress made since the last inspection, followed by the examination of six care records. In order to gather evidence on how the home is performing, individual discussions took place with five residents. In addition, four care staff were spoken with during the visit and a visiting General Practitioner. A detailed inspection of the premises and its facilities took place. 22 residents were accommodated at the time of the inspection. Other records and documentation inspected included: the home’s medication procedures, health and safety records, the home’s accident book, and a sample of recruitment files. What the service does well: What has improved since the last inspection? What they could do better: The home’s care planning procedures need to be more detailed and person centred, to ensure that all assessed needs are met by the home, this includes the assessment of all potential risks. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 6 In order to protect residents from harm the home needs to tighten up it’s recruitment procedures and ensure that all staff are aware of updated policies and procedures in relation to Adult Protection. 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 H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 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 standard(s) 1, 3 and 6. All prospective residents are provided with sufficient information in order to help them in their decision of where to live. Good systems are in place to ensure that no person is admitted to the home whose needs cannot be met. EVIDENCE: Many of the residents spoken with said that they had been affiliated with Holy Cross Priory and the Sisters over many years, and that it was ‘their friendliness and kindness’ that helped to support their decision to move in to the home. Since the previous inspection, the home has updated its Statement of Purpose and Service Users’ Guide. 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. One identified person is responsible for ensuring that all prospective residents’ needs are assessed prior to admission to the home. Three pre-admission assessments were seen on the day of inspection. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 9 All were found to be detailed, thorough and contain a needs assessment according to the resident, their relatives and the assessor. Intermediate care is not provided. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9. The current care planning systems in place do not ensure that all health and social care needs of residents are identified, met and any potential risks reduced. These shortfalls have the potential to place residents at risk. EVIDENCE: The individual plans of care within the home are currently based on a medical model, and therefore do not allow for detailed information to be included in relation to individuals’ social and holistic care needs. A new format is being developed by the home in order to address these needs. These were discussed in detail during the inspection and at a follow up visit to ensure that the new care plans are person centred, detailed and user friendly. Although a number of risk assessments are in place, it was noted that they did not provide staff with sufficient detail with regard to the action that is to be taken to minimise any potential risks, particularly with regard to the prevention of falls. A requirement has been made in respect of this. Many of the Sisters and lay staff are qualified Registered General Nurses. A concern was raised in the previous inspection report that nursing interventions were being carried out, which is not within the home’s category of registration. Since this time, all job descriptions have been amended to specify the boundaries of senior staff. Regular advice and support is sought on an individual basis from Community, Continence and Tissue Viability Nurses. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 11 The home’s medicine storage and administration system was viewed. It was pleasing to note that since the last inspection the home has amended it’s drugs error procedure, now keeps an accurate running total of controlled drugs in a bound book with numbered pages, implemented good practices to reduce the risk of medicines being dropped and have developed a robust system for promptly returning medicines no longer prescribed. However a number of recording errors were found. In addition the above, a box of unused syringe needles were being stored within the home. As the home is not registered to provide any nursing interventions or procedures, it was required that these were disposed of safely on the day of inspection. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 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 standard(s) 12 and 15. The arrangements in place for the provision of daily social activities are managed well by the home. All residents receive a varied, wholesome and nutritious diet. EVIDENCE: All of the residents spoken with confirmed that a variety of stimulating leisure and social activities are offered by the home, however many choose to remain in their own rooms either knitting, watching television or reading. An outing was planned for the following day, for residents to go to Beachy Head (a local beauty spot) for lunch. Transport had been arranged via Age Concern. Due to the rural location of Holy Cross Priory, local amenities are not easily accessible. Many of the residents are either reliant on their friends and relatives to take them out, or on some occasions they may order a taxi to take them to the local village. All of the residents spoke highly of the food provided by the home. Comments included ‘excellent’ and ‘often too much’. Menus are planned on a two weekly basis and offer a variety of tasty and nutritious food. Alternatives can be requested each morning. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. Holy Cross Priory has adequate systems in place to protect residents from harm and abuse, however it needs to ensure that all staff are aware of the procedures that are to be followed. EVIDENCE: Since the last inspection the home has updated and amended it’s Adult Protection Policy in line with local multi-agency guidelines. All staff confirmed that they had received training on the Protection of Vulnerable Adults, which is updated annually. However it was concerning to note that not all staff members spoken with were aware of the updated policies and procedures that are to be followed in the event of suspecting harm or abuse. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24, 25 and 26. Holy Cross Priory provides residents with a safe, comfortable and wellmaintained place to live. EVIDENCE: Since the last inspection the home has worked hard to improve the overall decorative state of the building. Many bedrooms and other areas of the home have been redecorated. In addition, new furniture and fittings have been purchased including: new chairs, curtains, carpets, wardrobes, and new beds. The front entrance of the building has also been re-surfaced. The home has a maintenance programme in place for minor repairs such as the re-fitting of light-bulbs and broken locks etc. Risk assessments were in place for the use of portable heaters and removed window restrictors, which were considered to be adequate. On the day of inspection the home was clean and pleasant throughout. The laundry floor and sluice rooms have recently been installed with a permeable floor covering and suitable hand washing facilities. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29. This home employs adequate numbers of staff to meet the assessed needs of residents, however the procedures for the recruitment of staff need to be improved. EVIDENCE: A total of 25 staff are employed to work at Holy Cross Priory comprising of 15 care assistants – eight of which are trained to a minimum of NVQ level 2, maintenance and administrative staff, and cooks. All of the residents and staff spoken with confirmed that the home is always adequately staffed to meet the assessed needs of the residents accommodated. A large number of the staff team are Sisters from India, Africa and Sri Lanka, who come to England for a period of several years. All are able to converse well in English. In addition some lay staff are employed. A key working system supports consistency and continuity of the care being provided. Three newly appointed person’s recruitment files were seen on the day of inspection. It was pleasing to note that since the last inspection no person is employed to work in the home prior to a Criminal Record Bureau and POVA First check being carried out, two appropriate written references being obtained and a proof of identification. However, the home’s application form still does not allow for a detailed history of employment details including: their start or leaving date, or their reasons for leaving. A requirement has been made in respect of this. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38. Holy Cross Priory has good management and administration systems in place, and suitable health and safety checks to ensure that residents are safe, however, thorough details of all accidents must be recorded. EVIDENCE: Since the last inspection the Registered Manager of the home has obtained her NVQ level 4 in Management. She has over 6 years experience in managing the home and has worked hard to meet the requirements of the previous inspection report. All of the residents and staff spoken with spoke highly of her management and leadership skills. Written guidance is available for all staff to follow in relation to aspects of health and safety throughout the home. A new accidents report book has been purchased since the last inspection, however it was concerning to note that not all reports were detailed with specific reference to what the accident was, or how it occurred. A requirement has been made in respect of this. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 17 A number of log books and certificates were seen on the day of inspection including: emergency lighting and fire equipment checks, lightning conductors, lift and host maintenance and gas and electricity certificates. All staff received an external update in fire training in June 2005. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 x x x x x x 2 Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? 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 15(1)(2) (a-d) Requirement It is required that care plans detail the action that is to be taken by staff to meet individuals assessed personal and social care needs [THIS IS OUTSTANDING FROM THE TWO PREVIOUS INSPECTION REPORTS]. It is required that comprehensive risk assessments are completed for all residents with particular regard for the prevention of falls. These should be in accordance with the guidelines produced by the National Institute for Clinical Excellence [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT] It is required that medicines are only signed for once they have been administered. It is required that equipment for nursing interventions (needles and syringes) are not stored in the home. It is required that all staff working in the home are aware of the procedures that are to be followed in the event of suspecting abuse. Timescale for action 22/11/05 2. OP7 13(4)(c) 22/10/05 3. 4. OP9 OP9 17(1)(a) Schedule 3(k) 17(1)(a) Schedule 3(k) 13(6) 22/08/05 22/08/05 5. OP18 22/08/05 Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 20 6. OP29 19(1) Schedule2 7. OP38 13(a) It is required that no person is employed to work at the home prior to a full employment history being known. This must include details of the start and leave dates and their reasons for leaving. In addition all gaps in employment must be accounted for [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT]. It is required that accident reports are recorded in sufficient detail regarding what the accident was and how it occured [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT] 22/08/05 22/08/05 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 OP1 OP29 Good Practice Recommendations It is recommended that all reviewed and amended documents are dated in order to evidence that they are current. It is recommended that the home review and amend its recruitment application form to allow for a detailed history of employment including: start and leave dates and their reasons for leaving and to account for any gaps in employment. Holy Cross Priory H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 H59-H10 S21140 Holy Cross Priory V230244 280605 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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