Inspection on 14/06/05 for Little Sisters Of The Poor

This inspection was carried out on 14th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Little Sisters Of The Poor 27/04/07

Little Sisters Of The Poor 24/11/05

Little Sisters Of The Poor 13/01/05

Little Sisters Of The Poor 19/07/04

Little Sisters Of The Poor 04/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

The Gardens Care Home

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

CARE HOMES FOR OLDER PEOPLE Little Sisters of the Poor, Holy Cross Home Ettrick Grove High Barnes Sunderland SR4 8QA Lead Inspector Clifford Renwick Unannounced Monday 14 June 2005 10:00 th 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. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Little Sisters of the Poor Address Holy Cross Home Etterick Grove High Barnes Sunderland SR4 8QA 0191 567 0862 0191 564 2026 Lspsund@aol.com Little Sisters of the Poor Religious Foundation 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) Sister Kathleen McMahon (Sister Roseline) Care home only 46 Category(ies) of DE Dementia (14) registration, with number PD Physical disability (4) of places OP Old age (46) Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13.01.05 Brief Description of the Service: The Holy Cross home provides care to older people over the age of 65 years and some of who may have dementia or mental health needs or a physical disability.The home provides personal care only and any health needs are dealt with by the Community Nursing Services.It is a large detached brick built house, which offers accommodation over 3 floors, as well having its own chapel and living accommodation for the sisters.It stands within its own grounds, which are extensive and also feature a religious grotto with a range of seating being available that service users and their families can use.The physical standards of this home are in excess of the National Minimum Standards.There are strong community links with the services that they provide which includes a day service and luncheon club.The Mother Superior who is the registered manager and throughout the report is referred to as mother manages the home. The manager is assisted by a team of “sisters” all of whom belong to the order of the Little Sisters of The Poor and who are referred to as “sisters” throughout this report.The home is situated at High Barnes, leading off from the Chester Road. A small thriving shopping centre is a short walking distance from the home. The shopping centre has a post office, chemist, local grocery shop, newsagent and public house.There is easy access to a bus service, which offers access into the City Centre where a range of services and shops can be accessed. A regular bus service operates from the front of the home. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours and was carried out as part of the statutory twice-yearly inspection process. Selected areas of the premises were viewed which included all communal areas and six bedrooms. A range of records were examined which included residents care records as well as records that related to health and safety and staff employed in the home. Discussion took place staff and also with relatives of residents who were visiting at the time of the inspection. Lunch was taken with two residents and discussion also took place with 8 residents and time was spent observing staff practices. It was established in discussion that the people who live in this home prefer to be known as residents and this term of reference is used throughout the report. The judgements made are based on the evidence available at the time of the inspection. What the service does well: The service actively involves residents and their families about how the home is run and they are encouraged to be involved in the day-to-day decisions. Good use is made of the community such as the shops and local facilities and residents continue to attend a church of their choice as well as making use of the chapel in the home. They also have access to the resident chaplain. The atmosphere can be best described as homely and friends and relatives of relatives are encouraged to be involved in the home. Good use is made of volunteers to help out within the home in a variety of roles. The manager ensures that staff receives appropriate training to increase their knowledge and skills. The manager takes an active part in the day-to-day running of the home. Every resident has access to her should they need to discuss any matters. In discussion with the residents they spoke positively of “mother” and also the “sisters” and staff. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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 Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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) 2, 3, 4 No one moves into the home until an assessment of needs has taken place and this ensures that each residents needs can be met and inappropriate admissions avoided. Each resident is issued with a copy of their terms and conditions of residence, which informs them of the services that are offered in the home. EVIDENCE: Examination of a case file for the one resident who has recently moved into the home confirmed that a comprehensive assessment had been completed however the home had not confirmed in writing to the resident/representative that their needs could be met in the home. The case files confirmed that additional assessments, which relate to risk of falling and pressure care had been completed and these had assisted staff in dealing with care needs. Part of the assessment process contains a good range of information about residents personal and social history and this is used by staff to assist in the development of individual care plans. On admission a copy of the terms and conditions of residence are issued to the resident. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 10 Resident’s care plans are in place, but these do not always reflect the positive actions being carried out by staff. The guidance available regarding care practice and health related needs are fully met. The Health and personal care needs of service users based on their care plans are met in a way which treats them with respect and promotes their rights and privacy. EVIDENCE: Four resident’s care plans and care files were examined and discussion took place with care staff about the work that they were carrying out. Each resident has a care plan but they do not always include the specific detail of work or actions that staff take when addressing needs. Yet it was clear that staff have a thorough understanding of individual service users needs. Staff were able to describe in detail why they carried out care processes in a particular way and relate these practices to professional models of care. Extensive records are in use, which confirm that resident’s health needs are met with good use being made of health professionals. The individual assessments in the area of falls and pressure care ensure that staff carry out a Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 10 regular analysis of individual service user needs and are able to intervene quickly if a resident is at risk. Examination of case files confirmed that resident’s are referred to by their chosen form of address and observations made confirmed that staff at all times treat residents with respect. Care practices being carried out by staff also confirmed that there is a dignified approach to the work and personal and intimate care tasks are carried out in the privacy of resident’s bedrooms. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 15 Resident’s are encouraged and supported to lead active lifestyles based on their preferences and choices. Residents are supported to follow their chosen religious beliefs. Friendships and relationships with people outside the home are encouraged. The meals offer a good balanced diet which promotes healthy eating and resident’s have the opportunity to comment on the meals, which results in meals being offered which reflect their choices. EVIDENCE: Discussion was held with four relatives during the visit and they confirmed that they were very satisfied with the care services; a positive feature of the home was resident’s being able to continue with their religious beliefs. They spoke positively of the staff and also the “sisters” stating that the “care was second to none”. Discussions held with resident’s confirmed that they too were very satisfied living in the home and said that if they raised any matters with the staff about the service, they were listened to. They cited the meals as an example stating that they could enter their comments about the food in a book and these comments were then passed to the catering staff who took note of the comments and adjusted the menus accordingly. Lunch was taken with two resident’s and it was positive to note that food is served in tureens enabling resident’s to choose what they eat and also what portion size they have on their plate. A range of hot and cold drinks were available throughout the meal Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 12 and for those resident’s who required assistance to eat their meal this was provided by staff in an unobtrusive way. Dining in the home is a pleasurable experience and similar to dining in a good quality restaurant. This view were also expressed by people who come into the home to make use of the luncheon service. In discussion with resident’s they stated that the outings on a Wednesday had commenced but due to a shortage of drivers these were going to be limited. This was discussed with the mother superior, to resolve. Resident’s also spoke of the problems with not being able to receive the satellite religious channel on their television set stating that it had been unobtainable for some time. In discussion with the mother superior she confirmed that she was aware of this and an engineer had been contacted. One resident has been taking music lessons in order to be able to play his electronic organ more professionally and he was keen to show me his certificates of achievement. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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) 16 Complaints in the home are handled objectively and openly with the manager and staff encouraging resident’s, their friends and families to offer comment on the services that are offered. Resident’s are confident that any complaints made are acted upon. EVIDENCE: In discussion with resident’s they confirmed that they were aware of the complaints process and would have no hesitation of raising any concerns with staff. They spoke of how they can comment on the food either by filling an entry in the catering book or even bringing it up at the residents meetings. They went on to say that when they had raised matters particularly with the food it had been acted upon immediately. Minutes of residents meetings confirmed that staff responds positively to issues raised by the residents. The complaints process is widely publicised in the home and a copy of how to complain is issued with resident’s contracts. Throughout the discussion residents confirmed that they had no complaints and everyone spoken to confirmed how satisfied they were in the home. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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, 26 The home is clean, well decorated and maintained. This promotes a positive image for resident’s, and ensures that they remain safe. EVIDENCE: A good standard of decoration and furnishing is in place in all areas of the home. All communal areas and a sample of bedrooms were viewed on two floors of the building and these were clean and well maintained and furnished to suit resident’s choice. Ongoing maintenance was being carried out at the time of the inspection, which included the renewing of light bulbs. There were no noticeable safety hazards or repairs identified during the visit. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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, 29 The deployment and number of staff on all shifts ensures that at all times resident’s are supported by an experienced group of staff. Staff recruitment practice and record keeping in respect of new staff employed in the home, is robust and assists in ensuring that service users are protected. EVIDENCE: Examination of staffing rosters confirmed that appropriate staffing levels are maintained and additional staff support is available from the “sisters” who work in the home. Discussion with the member of staff responsible for personnel confirmed that the same level of recruitment checks that are carried out for staff are also carried out for volunteers who work in the home. Staffing files are also in place for “sisters” who transfer from other establishments and access to these is restricted to the mother superior. Discussion took place with “mother” about the need to amend and develop the homes application form in order to ensure all gaps in employment are explored and that staff complete a health declaration. The mother superior agreed steps were being taken in this area. However due to these amendments having an impact on other homes that use the same documentation this would take some time to change. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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) 33, 38 The manager ensures that all staff have guidance and support so that resident’s needs are met effectively. Arrangements to ensure that the health, safety and welfare of resident’s and staff are in place, and are successful in maintaining safety within the home. EVIDENCE: Discussion held with staff, resident’s and also the “sisters” confirmed that the mother superior has made a number of positive changes in the home especially with resident’s outings. Staff confirmed that they receive training appropriate to their work and support is available from both the “sisters” and “mother”. Appropriate records are in place, which confirms that health, and safety matters in the home are addressed. A checklist is in place which has been designed from guidance in the Fire Precautions (Workplace) Regulations, to confirm how fire precautions are maintained in the home. The fire logbook Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 17 confirmed that staff receive appropriate fire instruction training and take part in regular fire drills. Regular hot water checks are carried out at all hot water outlets and records are maintained to confirm this and whether any remedial action has been necessary. Detailed records of accidents in the home are also maintained. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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 x 3 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x 3 Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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 4 Regulation 14 (1) (d) Requirement Timescale for action Immediate 2. 3. 7 29 15 19 (4), (b), (i) 4. 29 19 (5), c Confirmation must be made in writing that service users needs can be met in the home on the basis iof the assessment that has been completed. Residents care plans must 31.12.05 continue to be developed as advised during the inspection. The application form for staff 31.12.05 must be amended to confirm that all previous employment is listed in support of any application for work in the home.(Outstanding since 13.01.05) As` part of the satff recruitment 31.12.05 process staff must complete a declaration confirming that they are physically and mentally fit for the work they are to perform in the home.(Outstanding since 13.01.05). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 20 Little Sisters of the Poor, Holy Cross Home 1. 2. Standard 12 12 Consideration should be given to providing a male person to carrty out the weekly physicla exercise sessions with residents. Steps should be taken to providing more drivers for the homes minibus in order to ensure that social outings are carried out on a regular basis. Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT 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 Little Sisters of the Poor, Holy Cross Home B52 B02 S15715 Holy Cross V219594 13 Jun 2005 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. 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