Inspection on 23/11/05 for More Hall Convent

This inspection was carried out on 23rd 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

More Hall Convent 16/05/07

More Hall Convent 28/02/06

More Hall Convent 16/02/05

More Hall Convent 02/11/04

More Hall Convent 25/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE More Hall Convent Randwick Stroud Glos GL6 6EP Lead Inspector Janice Patrick Unannounced 23rd November 2005 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. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service More Hall Convent Address Randwick Stroud Glos GL6 6EP 01453 764486 01453 764486 morehallbenedictines@tesco.net Grace & Compassion Benedictines 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 Jenita Antony Care Home only 15 Category(ies) of Old Age not falling within any other category registration, with number (15) of places More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th February 2005 Brief Description of the Service: This Care Home is run by the Sisters of the Order of Grace and Compassion Benedictines. Although the Order is Catholic, any denomination is welcome at More Hall. The Sisters care for the elderly person who requires help and supervision with their personal care and daily activities. The Home is well maintained and run in a way that takes into account the residents ideas and preferences. Accomodation consists of single bedrooms and ample communal rooms, including bathrooms and toilets. There are attractive gardens which are enjoyed in all weathers and ample car parking. The Home is wheelchair friendly and has a shaft lift for access to the first floor. There is also a ramped entrance to the side of the building. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection between the hours of 2.25pm and 6.30pm. The Registered Manager was on duty and the Deputy Manager made herself available during the inspection to go through the medication system with the Inspector. All staff were welcoming and helpful. Several residents were spoken to about their care and life at More Hall. Various records were inspected, these included care records, staff recruitment files, duty rosters, minutes to staff and resident meetings and various health and safety records. In addition the medication system was inspected, to include relevant records. The Complaints Log was also inspected. Areas of the Home were seen as the Inspector spoke with residents, but a full tour of the building was not carried out on this visit. What the service does well: What has improved since the last inspection? What they could do better: As identified already by the Manager the introduction of a recorded, structured training package for new recruits would help the Home meet with the Care Home Regulations. The Manager must also take care to ensure that all recruitment criteria are completed before staff commence in post. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 6 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. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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) 3 The pre assessment process in place ensures that staff are aware of a residents’ needs prior to their admission and therefore can be met once they arrive in the Home. EVIDENCE: Three residents’ pre admission assessments were inspected. In both cases close relatives had provided additional information, along with a social services Care Plan of Needs. The information in these documents had been transferred to the assessment carried out on admission and identified needs had appropriate care plans, demonstrating how these needs would be met. Individual preferences were also highlighted within the pre admission information. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 & 9 Care plans are written in a way that gives clear instruction to staff and demonstrates that the residents’ health and personal care needs are being met. The medication system is organised in such a way that ensures residents’ medication is administered and stored in a safe manner. EVIDENCE: The care documentation for two residents was read in detail. All assessments and care plans had been reviewed and updated within the dates recorded. Residents are included in their care reviews and those spoken to were able to demonstrate that they were well aware of their care plans. One resident was observed talking to the Manager about her needs and preferences. It was clearly evident that she felt comfortable to do this and that she was being listened to. In a subsequent conversation with her she confirmed that the Manager always sorted things out. In one case the resident had been seen and their health investigated by a NHS Consultant. There was evidence to show that the Mental Health Team had been involved. It was also noted that this resident had been prescribed a medication More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 10 used in the treatment of dementia following a Computerised Tomography Scan (CT Scan) of the head. The Manager was unaware of a diagnosis of dementia at this point, although it was clear on talking to this resident that there was severe memory impairment. The Manager confirmed that the Home could meet this individual’s needs at the present time. This situation will be closely monitored by the CSCI, to ensure all needs continue to be met. The Home does not have a category within its registration for dementia care. There is a process available for the Home to apply to vary its registration if needed. The medication system is organised by the Deputy Manager. Storage is clean and organised. All necessary records are kept for the processes of ordering, administration, review and returning to the Pharmacist. The Home has its own Policy for Medication Administration with relevant procedures. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 &15 The Home makes arrangements to meet residents’ individual choices and preferences. EVIDENCE: All residents spoken with agreed they are able to lead their lives the way they wish to, albeit depending on their daily health. They said they were happy and comments such as ‘the Sisters are lovely’ and ‘we can have a giggle’ were made. One resident explained that he followed the Quaker Faith. The Manager has arranged for regular Quaker meetings to be held at the Home in order for this resident to maintain his involvement. To have the freedom and ability to do this was clearly very important to this person. Requests to have more cold meats more frequently at tea- time were seen within the minutes of the last residents meeting. This request had been incorporated within the menus and was the tea on the day of this inspection. The Inspector spoke with four residents during their evening meal and all agreed the food was sufficient and tasty. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 standard(s) 16 Adequate arrangements are in place to ensure that any concerns or complaints can be raised easily and individuals are confident that these will be addressed appropriately. EVIDENCE: The Homes Complaint Log was inspected. There had been no formal complaints, but small concerns are also recorded and those seen had been dealt with appropriately. These tended to be related to individual choices of food. The Complaints procedure is in a prominent position in the Home and within the Home’s Service User Guide. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 standard(s) 19 The Home is safe and well maintained providing a pleasing environment for residents to live in. EVIDENCE: The Home has a committed maintenance person who works to a planned programme of refurbishment and decoration. The grounds and gardens are also kept tidy and attractive. Records show that the Home adheres to any recommendations made by the Fire Officer. The last Fire Officer’s visit was in August of this year and one door remains to be changed within the Sister’s accommodation, which the maintenance person has planned to do soon. The Food Safety Officer awarded the Home a ‘Fit To Eat’ certificate following his visit in November of this year. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 & 30 Thorough and comprehensive training arrangements ensure that staff are capable of meeting the residents’ needs. Arrangements for recruitment seen during this inspection were not meeting with requirements and therefore will not help ensure residents safety. EVIDENCE: The duty rosters were inspected. All Sisters’ within the Convent have a daily role within the Care Home, although there is a core team that provides personal care. These staff are trained accordingly and usually hold a NVQ in Care. The number of night care staff was reviewed with the Manager. She confirmed that the present arrangements of one waking and one sleeping, still meet the needs of the residents. The Inspector has been made aware in the past, that when the needs of the residents increase the numbers of staff at night has automatically been raised. As the Sisters live ‘on site’ it is understood that they are automatically available if required. Residents confirm that there are always enough staff to help them when needed. Two new staff members’ recruitment files were inspected. One member of staff had commenced in post before having a CRB/POVA clearance. There was evidence to confirm that this member of staff was receiving supervision at all times. The second file did not contain any references, but these have been subsequently forwarded to the Inspector. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 15 Records show that staff complete mandatory training and that a period of induction into the care role is undertaken. A senior Sister monitors this period of time. The Manager however, is planning to produce a structured booklet that will record all the elements of induction training and provide a record of learning, which can be used towards evidence required in the NVQ Award. This will also enable the Home to meet fully with the Care Home Regulations. As this has been identified as being required it has not been made a ‘requirement’ within this report, but the Home will need to demonstrate that arrangements are in place for a ‘structured induction’ in future inspections. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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) 32 & 38 The Manager has clear ideas on how the Home should run and is committed to residents being actively involved in this process. Arrangements are in place to ensure that residents live in a safe environment. EVIDENCE: Residents spoken to confirmed that they are actively encouraged to be involved in the decision making within the Home. The Inspector spoke with one resident who had taken the minutes for the last resident meeting. Her friend had acted as the residents’ representative and had chaired the meeting. These minutes were made available to all residents. The last staff meeting was held in November of this year and 10 members of staff attended. Several health and safety records were inspected. These demonstrated that the hot water, electrical appliances, call bell system and lift are being appropriately serviced and checked to ensure their efficiency and safety. More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 17 More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 x x x x x 3 More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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 29 Regulation 19 Schedule 2 Requirement The Registered Manager must ensure and demonstrate that all new staff have had an appropriate clearence by the Criminal Records Bureau (CRB) and have been cleared against the Protection of Vulnerable Adults (POVA) list before they commence duty at the Home. Timescale for action 03/01/06 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. Refer to Standard Good Practice Recommendations More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 More Hall Convent D51_D03_S16504_More Hall Convent_V197533_150805_Stage 4.doc Version 1.40 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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