Inspection on 24/11/05 for Little Sisters Of The Poor

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

Little Sisters Of The Poor 27/04/07

Little Sisters Of The Poor 14/06/05

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 Mr Clifford Renwick Unannounced Inspection 24th November 2005 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 Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Little Sisters Of The Poor Address Holy Cross Home Ettrick Grove High Barnes Sunderland SR4 8QA 0191 567 0862 0191 564 2026 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) Little Sisters of the Poor Religious Foundation Care Home 46 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (46), Physical disability (4) of places Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 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 who 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 DS0000015715.V253878.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by myself and another regulation inspector (Katie Tucker) in accordance with the twice-yearly statutory inspection process. The inspection took approximately 7 hours. The inspection focused on examination of records that related to staff recruitment, health and safety, medication and care plans. Inspectors joined residents for lunch. All communal areas were viewed and also a representative number of bedrooms on each floor. Discussion was held with 17 residents and also with 3 relatives who were visiting the home and discussion also took place with staff that were on duty. The judgements made are based upon the evidence available at the time of the inspection. What the service does well: What has improved since the last inspection? Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 6 Care plans which list how staff will support the residents with their personal needs are continuing to be developed and staff have had training in how to implement the care plans. Records, which are used for the recruitment of staff, are improved. 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 DS0000015715.V253878.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 The admissions process ensures that service prospective resident’s needs are assessed prior to care being offered. This helps to ensure that they are offered the right type of care at the home. EVIDENCE: Since the last inspection one person has been admitted to the home. Examination of their case file confirmed that a comprehensive assessment had been completed prior to offering this person a place in the home. The manager had also confirmed in writing to the resident that on the basis of the assessment their individual needs would be met in the home. Discussion held with the manager confirmed that no one would be admitted to the home without an assessment being completed. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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, 9, 10 The care plans continue to be developed and the manager is aware of how further developments are required. The ‘sisters’ and training co-ordinator are putting measures in place to make sure these records include more detail of how staff meets resident’s needs. Medication administration procedures ensure that the resident’s health care needs are addressed. Staff have a friendly and respectful approach towards resident’s, which empowers them and gives them control over their lives. EVIDENCE: The Little Sisters of the Poor have developed an assessment tool for all of their care homes. The tool covers a wide range of areas and assists staff to gather appropriate information. The ‘sisters’ and the training co-ordinator are monitoring how this tool is used and care plans are produced from it. The staff have been learning how to write care plans and risk assessments more clearly. In September, one of the inspectors visited and provided additional training to a group pf senior staff about how to complete care plans. Staff are trying to make sure that more detail is recorded about the actions that need to be taken. Staff collectively knows what areas of person’s needs Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 10 they are concentrating on but this is not fully shown in the care plans. The ‘sister’s’ are auditing the resident’s files to monitor change in practice. They expect that as staff become familiar with what is expected the care plans will improve. Staff used to complete full social profiles and these were well written and extremely informative as well as being sensitively written. At the moment staff have not continued with this practice. It was suggested that they restarted writing these useful social profiles. Observations made confirmed that Staff worked well with residents. People’s privacy and dignity was considered at all times. Residents said that staff are always ‘respectful’. They also commented that staff really seemed to care about them. Residents make choices about their lifestyles. When people lack capacity to do this fully staff continue to help people to remain as independent as possible. Examination of the medication storage and administration systems confirmed that good systems are in place. Two residents are supported by staff to maintain control of their own medicines and this is backed up by good risk assessment documents being in place. Staff have a policy of carrying out regular discrete checks to ensure that these residents continue to manage their medicines safely. Senior staff are responsible for administering medicines in the home and have received appropriate training. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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): 14 Residents are encouraged and supported to lead active lifestyles based on their preferences and choices. Friendships and relationships with people outside the home are encouraged. EVIDENCE: Residents are encouraged to follow their own routines. People continue to remain as independent as possible and staff offer help in a sensitive manner. People, when able, continue to drive, go out on their own and go on holiday. One person regularly has music lessons and is learning how to play the organ. Other people can choose to join in the activities within the home or not, as they wish. Residents commented about the caring attitude of staff and how staff would do anything for them. Staff were observed to be working with people in a very sensitive and discreet manner. The home operates as a community and residents are encouraged to contribute to the community spirit. The home has their own resident chaplain who performs mass in the chapel. Residents regularly make decisions about the operation of the home and hold meetings with the ‘mother’. Residents commented that their suggestions had always been taken on board. A new ‘mother’ has taken up post and all were very complimentary about how she listened to them and took up their suggestions. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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): 18 Robust procedures are in place that ensures residents are protected from abuse. EVIDENCE: Comprehensive policies and procedures are in place that deals with the protection of vulnerable adults. Staff have received training in this area. Discussions held with staff confirmed that they are aware of the procedures and whom they would report any concerns to. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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, 20, 24 Holy Cross provides a good standard of personal and communal accommodation. The home’s premises are maintained to a good standard. EVIDENCE: The Holy Cross has been greatly refurbished over that the last few years. The laundry was renewed and this was of a standard that would be seen in industrial laundries. Also the staff facilities have been enhanced and a smoking and non-smoking staff rooms plus a shower are now provided. The home provides a wide range of lounges, dining rooms, activities rooms, libraries, smoking areas, a shop and a chapel. A very large dining room is situated on the ground floor as well as a number of rooms for activities. There is an immense garden with a grotto at the front of building. The range of communal areas is well in excess of that required in this standard. All areas offer good disabled access. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 14 The bedrooms are all in excess of the requirements of this standard. Residents are encouraged to personalise their bedrooms. The bedrooms are furnished to a good standard and specially adapted beds are provided where appropriate. All areas of the home were well maintained. Residents again commented that the home was always extremely clean. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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 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, 30 The procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. A well-trained staff team meets the resident’s needs. EVIDENCE: Several staff have been appointed since the last inspection. Examination of their personnel files confirmed that the home obtain all of the relevant documentation as required in respect of their employment. This includes a written declaration by staff that they are physically and mentally fit for the work they are to perform. A record is also obtained of any gaps in employment is also obtained and kept on their personal file. A comprehensive inductiontraining programme is in place for new staff. There is also an annual training programme for all staff, which is good. Since the last inspection the home have appointed a new training coordinator to replace the previous trainer who has now ceased to work in the home. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 38 The manager offers clear leadership and direction to the staff so that they can consistently meet the needs of residents. Residents are asked by the organisation and by staff about how they want their support to be provided so that their rights and best interests are promoted. The arrangements for the handling of resident’s personal savings serve their interests well. The health and safety of the residents is promoted by a well managed staff team. EVIDENCE: A new mother superior has been appointed since the last inspection and holds responsibility for the day-to-day management of the service. The commission is currently processing an application for registration in respect of the “mother”. The “mother “ is an experienced manager who is also a qualified nurse and has previously held the registered managers post in a number of the organisations other homes. The home holds personal allowances for 4 residents and the records used to record this are well maintained. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 17 Examination of fire records and fire logbook confirmed that good arrangements are in place to ensure that staff receive regular fire instruction and fire drill training. Good health and safety practices are in place and there were no noticeable hazards at the time of the inspection. Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 4 4 X X X 4 X X 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 3 X X X 3 X X 3 Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 19 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 OP7 Regulation 15 Requirement Residents care plans must continue to be developed as advised during the inspection. Timescale for action 14/06/05 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 Standard Good Practice Recommendations Little Sisters Of The Poor DS0000015715.V253878.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South of Tyne Area Office 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 DS0000015715.V253878.R01.S.doc Version 5.0 Page 21 - 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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