Inspection on 28/02/06 for More Hall Convent

This inspection was carried out on 28th February 2006.

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

The inspector 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

More Hall Convent 16/05/07

More Hall Convent 23/11/05

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 Mrs Janice Patrick Unannounced Inspection 11:25 28th February 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 More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service More Hall Convent Address Randwick Stroud Glos GL6 6EP 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) 01453 764486 01453 764486 sisterjenita@antony1.fsnet.co.uk Grace & Compassion Benedictines To be Appointed Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 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. Accommodation 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 DS0000016504.V278241.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection between 11.25am and 3.30pm. The acting Manager was on duty including other members of the home’s team. Ten of the core standards were inspected. Four residents were spoken with in some length to ascertain their views on the care given and services provided. Particular attention was paid to how the staff maintain residents’ privacy and dignity, resident choice and how vulnerable residents are protected against harm or abuse. Progress in staff training in the National Vocational Qualification (NVQ) award was discussed. The general environment and its level of cleanliness was inspected. The arrangements in place for the safe keeping of residents’ personal monies were inspected. The home’s systems for ascertaining the views of residents and how improvements in the care and services delivered, were inspected and discussed. The progress of the acting Manager was discussed. What the service does well: What has improved since the last inspection? What they could do better: It would benefit the home with regard to future changes in the regulatory requirements, if it expanded and broaden its quality assurance system. The records held pertaining to residents’ personal monies must be accurate at all times. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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 DS0000016504.V278241.R01.S.doc Version 5.1 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 More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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): 6 This home does not provide designated intermediate care. EVIDENCE: N/A More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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): 10 Personal care and support is offered in such a way that the residents’ privacy and dignity is upheld at all times. EVIDENCE: The residents spoken with on this inspection reiterated the views that have always been voiced within this home, that their privacy and dignity is always maintained and the ethos of the home evolves around this core individual right. One resident assured the Inspector that there were many in the home that would speak out and say if this was not so. All those spoken to during this visit appreciated the privacy that they are able to maintain despite living within a community. All sisters and care staff were observed to be upholding this by knocking on doors before entering bedrooms and interacting with residents in such a way that acknowledged that this was very much their home. One frail resident was observed to be eating in the lounge area in the company of one of the care staff. The Inspector asked why this was and it was explained that as she had become more physically frail she had also become more mentally frail and unable to maintain the socially accepted eating habits that More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 10 she had previously maintained. In order to protect her dignity and shelter her from awkward comments that were being made she now sits quietly with a member of staff in the lounge. The resident appeared very content and was free to feed herself without judgement. The family had also been involved in deciding on the best course of action for her and felt this to be the better option. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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): 13 & 14 Residents are very much in control of their lives and arrangements are in place to support freedom of choice and freedom to socialise as they wish. EVIDENCE: Each resident within this home has very different ways of approaching daily life which indicates to the Inspector that the individual resident is the driving force behind how they spend their day and who they see. There were several references to support this such as, ‘ I do not like to get up too early, so I go to the later mass’, ‘ I do what I like during the day and I can even make myself a cup of tea when I like’, ‘Can you explain to me what your regulations say about the servicing of walking frames’. This resident is a key person within the residents committee and is able and feels free to question areas of the inspection process and the regulations that have a direct affect on her and others. One resident confirmed that her daughter visits regularly; another sees her son most days. Another resident explained that she did not have any close relatives only one distant relative ‘the sisters are my family and of course I have my cat here’. Residents indicated that they have the freedom to make their own arrangements regarding their finances. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 12 More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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): 18 Formal arrangements and the core beliefs within the home help protect residents from abuse. EVIDENCE: All residents spoken to during this inspection and on previous inspections have confirmed that they are treated in a way that is always kind and thoughtful. One resident said ‘they are very caring’ another said ‘they are so patient even with those that get a bit confused’, ‘I think some people here can sometimes be very rude and the Sisters are still always very patient’. The home’s Adult Protection Policy had been reviewed in January of this year and corresponded with the county’s protocol for Adult Protection. The Whistle blowing Policy had been updated in May 2005. One of the care staff spoken with was aware of the potential risks relating to adult abuse, but admitted she had not read the home’s policy for some time. She had received some adult abuse awareness training recently. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 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 & 26 Residents live in a home that benefits from regular maintenance and which is clean. EVIDENCE: The home has a rolling programme of maintenance work and decoration some of which the Inspector cross-referenced against ‘actual’ completed works. Several bedrooms have been decorated since the last inspection and one was being completed the day of this inspection. The maintenance person is very committed to the home and much liked by the residents. One resident said, ‘nothing is ever too much trouble’. All Sisters within the convent are responsible for keeping the care home clean. All areas are exceptionally clean and good infection control is practiced. Available for staff when required are plastic aprons and gloves and clean aprons are worn when serving food. Liquid soap is used rather than communal bars of soap. A clinical waste policy is in place and adhered to. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 15 The laundry floor has been sealed and painted since the last inspection and the room was organised and particularly clean. Soiled clothing/linen is segregated and washed appropriately. Residents confirmed that their bedrooms are clean regularly. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 16 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): 28 Arrangements are in place to ensure all care staff receive appropriate training in order for them to meet the residents’ needs. EVIDENCE: All Sisters and the majority of care staff already hold or are undertaking NVQ training in care. At the time of this inspection two new Sisters had commenced NVQ Level 2 at the local college. One Sister was commencing the NVQ Assessors course. The acting Manager has commenced her Registered Managers Award and NVQ Level 4 in Care and on the day of this inspection, had the first visit from her allocated college assessor. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 17 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, 33 & 35 Although a recent change in management has taken place, residents are confident that the new Manager is going to continue running the Home in their best interest. The home’s quality assurance system would benefit from broadening, although residents views are actively sought. Arrangements are in place to ensure residents’ personal monies are kept safe, although some improvement in the record keeping is needed. EVIDENCE: On joining the Order the Sisters are aware that they maybe asked to move at any time within the Order. This happened after Christmas to the previous Registered Manager who had run the Home very successfully and who has now moved to manage a larger Care Home within the Order. The then, previous Deputy Manager is now the acting Manager and has made an application to the CSCI to become the next Registered Manager. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 18 She has been caring for the elderly person for many years and accumulated valuable management experience in her role as Deputy. She is very popular with the residents and staff alike who feel she will do well in her new role. There are systems for ensuring that the residents’ views are heard and listened to. A satisfaction questionnaire dated January 2006 had not yet been sent out to residents, but one is carried out each year. Residents confirmed that there are plenty of opportunities for open discussion. The residents who cannot or who do not wish to attend a meeting, can put their view forward through the Chair of the residents committee. This role changes amongst the residents who are also responsible for taking the minutes. The registered provider also carries out an unannounced visit to the home on a monthly basis to ascertain the views of the residents and to ensure the home is running smoothly. A written report is subsequently submitted to the CSCI each month. The arrangements for the save keeping of small amounts of personal monies were inspected. Records are kept along with receipts for any expenditure. The records of 3 residents were seen and although all the above was in place each resident had more in their ‘in house’ account than was recorded. Although it would appear that the residents have made a profit, it is important that these records are accurate at all times. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X X More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 20 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 OP31 Regulation 9 Requirement Timescale for action 17/04/06 2. OP35 Schedule 4(9)(a) The acting Manager must be registered with the CSCI and passed as a ‘fit person’ to manage the care home. The Registered Person must 17/04/06 ensure that all records pertaining to the transactions of residents’ personal monies correspond with the actual amount kept, at all times. 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 OP33 Good Practice Recommendations A system should be adopted for the measuring of the standard of care and services delivered within the home and this should have related aims, goals and achievements recorded. This could then help to formulate the care home’s annual development plan. More Hall Convent DS0000016504.V278241.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Gloucester Office Unit 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 DS0000016504.V278241.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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