Inspection on 18/10/05 for Maryfield Convent

This inspection was carried out on 18th October 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

Maryfield Convent 08/01/09

Maryfield Convent 09/01/07

Maryfield Convent 07/03/06

Maryfield Convent 23/12/04

Maryfield Convent 01/09/04

Maryfield Convent 05/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Maryfield Convent London Road Hook Hampshire RG27 9LA Lead Inspector John Vaughan Unannounced Inspection 18th October 2005 10:35 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 Maryfield Convent DS0000012262.V259641.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. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maryfield Convent Address London Road Hook Hampshire RG27 9LA 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) 01256 762394 Congregation of Dominican Sister Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a service user with the date of birth 12/08/1920 in the category MD(E). 23rd December 2004 Date of last inspection Brief Description of the Service: Maryfield residential care home is registered to provide accommodation for 26 people who are within the category of old age. The home is owned and managed by the Congregation of Dominican Sisters of Malta. The home endeavours to provide a homely and relaxed environment for service users. Staffing is provided twenty-four hours a day. Visitors are welcome and service users families are encouraged to play an active part in their relative’s life where appropriate. The home has well-established links with local General Practitioners and nursing services to support and enhance the care provided. The home is situated in a small village of Hook and is set within the grounds of the convent, which is attached. The home is a three-storey building and accommodation is provided on the upper two floors. The home has restricted its admission numbers at present to thirteen on the first floor only. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours and involved the service users, staff members and the manager of the home. The inspector spoke with service users, visitors and staff, toured the home and examined records during the visit. What the service does well: 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. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 6 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 Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 7 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 and 5 Clear assessments mean that the home can demonstrate that service user’s needs are recorded and acknowledged. The homes admission practices demonstrate that service users and their families are able to make judgements about the suitability of the home. EVIDENCE: The inspector sampled needs assessments for three new service users admitted to the home since the last inspection and found them to be comprehensive. The assessments were carried out by one of the sisters and covered health and wellbeing, mobility including falls, family contact and interests & hobbies. The inspector discussed the admission process with service users and family members. All spoke positively about the move into the home and had opportunities to visit prior to moving in. The inspector also saw information Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 8 and correspondence from family members and representatives to confirm visits and discussions taking place prior to the service users moving into the home. The home welcomes prospective service users and their families to come and visit the home prior to making a decision. Intermediate care is not provided in this home therefore standard 6 is not applicable Maryfield Convent DS0000012262.V259641.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, 8 and 10 Services user’s plans and risk assessments demonstrate that service users needs and wishes are acknowledged and responses to meet these needs are documented. The home provides support for service users to access health Care professionals to meet their needs. EVIDENCE: The inspector examined a sample of three service user’s plans. The information provided is clear and concise. These plans include instructions for staff on how to support each individual with day-to-day activities including personal care and communication. At the last inspection the manager and staff discussed the development of their risk assessment strategies. The inspector confirmed that the strategies for moving and handling, using the hoist, the use of bedrails and unrestricted windows are now in place. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 10 The inspector was informed that staff work closely with the GP and district nursing practice. Service users attend regular medical appointments and are supported by staff when necessary. Arrangements are made for chiropody, sight and hearing assessments. Service users confirmed that they have weekly visits from the GP and that they are supported to attend appointments as necessary. Through discussion with service users and feedback from relatives the inspector was able to confirm that service users are treated with respect and dignity. The inspector observed staff knocking on doors and asking permission to enter rooms. Service users commented that the sisters are friendly and very caring. Maryfield Convent DS0000012262.V259641.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): 12, 13 and 14 The home has an activity programme, which meets the needs of service users and is enhanced by regular contact from families and friends. EVIDENCE: The inspector spoke to service users with regard to the activities in the home. A room is available for service users to engage in activities such a cards and scrabble. A number of service users prefer to spend time in their room engaged in reading or pursuing their own hobbies. One person showed the inspector some very detailed family research they had carried out. During the summer events were organised in the garden. Visits to garden centres and shopping trips were also arranged. The inspector receives updates on these events through the regulation 26 reports he receives from the home on a monthly basis. The inspector discussed activities with a number of service users who all expressed a general satisfaction regarding the level of activity and stimulation in the home. Family members also confirmed their satisfaction and said that the level of activity reflects the age and needs of their relative. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 12 Service users also commented on the large accessible and well laid out garden which they enjoy walking around each day. On the day of the inspection some service users were enjoying a coffee together after morning mass. The home has no restrictions on visiting. Service users and people visiting on the day confirmed this. Service users told the inspector about visits to local restaurants and pubs for meals with their families. Service users also go to the local shops situated in the village, which is very close to the home. The home has service user’s meetings every 3 months and they are generally planned to coincide with major events. Minutes of these meetings are maintained and topics included celebrations, activities and menu planning. Service users are supported and encouraged to manage their own finances. The home does not manage or retain monies for service users. The inspector was able to confirm from records and viewing individual rooms that service users have brought their own furniture and possessions to the home. Service users have arranged their rooms to meet their own requirements. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 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 the following standard(s): 16 The homes practices demonstrate that concerns from service users and their families would be documented and responded to. EVIDENCE: The home has a clear complaints procedure. This is available to all service users their families, representatives and staff. There has been one complaint since the last inspection. This was made jointly by two service users about the pond being overgrown. The home responded promptly and the gardener carried out remedial work. The inspector talked with service users about raising concerns and confirmed that service users would be able to make complaints and knew who to speak to if they had any problems. Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The home provides a comfortable and well-maintained environment enhanced by a large garden enjoyed by service users. EVIDENCE: The inspector toured the building with assistance from staff in the home. Service users bedrooms are located on the first and second floors only. The ground floor has a dining room and further small rooms on the ground floor and a lounge on the first floor, which are used by service users for meetings and activities. The home has a large well-maintained garden, which is greatly appreciated by service users who told the inspector that they enjoy daily walks around the garden. The second floor is not in use at present and service users are only admitted to the first floor. The home was clean and tidy and free from any unpleasant smells. Maryfield Convent DS0000012262.V259641.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): 27 and 29 The homes recruitment procedures ensure service users are not put at risk however this would be enhanced by greater detail on information from the agency. EVIDENCE: The inspector examined the rota and confirmed that the levels of staff are maintained to meet service user’s needs. The manager stated that the ensure one member of staff is always in the home for assisting the few service users who do not attend mass in the convent chapel in the morning. No new staff have started in the home since the last check of recruitment records. The home use agency staff at night with one of the sisters on call should extra assistance be required. The home has been provided with a general letter from the agency saying they carry out checks on their staff. The manager was advised that they need a letter from the agency to clearly state that this person has all recruitment checks in place including a Criminal Records Bureau (CRB) check and two written references. Maryfield Convent DS0000012262.V259641.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 and 38 The home is well managed and actions are taken to ensure the health and safety of service users. EVIDENCE: The manager has experience of running this residential home and is supported by knowledgeable and dedicated colleagues. The manager has obtained her registered managers award. Service users are encouraged to maintained their own finances or appoint a relative of financial advocate to manage their affairs. The home does not hold monies on service users behalf. The inspector saw a well maintained home with records available to demonstrate that regular checks and servicing is carried out on the homes Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 17 electrical, heating and fire alarm system. Certificates were also in place for the servicing of hoists and the lift. Maryfield Convent DS0000012262.V259641.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 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action 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 Maryfield Convent DS0000012262.V259641.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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