Inspection on 10/11/05 for Mount St Joseph`s Home

This inspection was carried out on 10th 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

Mount St Joseph`s Home 08/05/07

Mount St Joseph`s Home 29/07/05

Mount St Joseph`s Home 10/03/05

Mount St Joseph`s Home 25/01/05

Mount St Joseph`s Home 27/02/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Mount St Joseph`s Home Shire Oak Road Leeds Yorkshire LS6 2DE Lead Inspector Hebrew Rawlins Unannounced Inspection 10th November 2005 10:30 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 Mount St Joseph`s Home DS0000001360.V262207.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. Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mount St Joseph`s Home Address Shire Oak Road Leeds Yorkshire LS6 2DE 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) 0113 2784101 0113 2305127 The Little Sisters of the Poor Sister Caroline Mary Kissane Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29/07/2005 Brief Description of the Service: Mount St. Josephs is a modern purpose built care home. It was built in Headingley and opened in December 1971. It is a residence for the elderly, owned and managed by the Little Sisters of the Poor. They are a voluntary religious organisation, which receives persons of modest income, of 65 years and over including single persons, or married couples. The nearest shops, bank and post office are in the Arndale Shopping Centre only 10 minutes walk away from the Home. Their philosophy of care is based upon the need to understand and respect people as individuals at all times, with the benefit of care staff providing care and reassurance 24 hours a day. The home is equipped with lifts and offers easy access for wheelchair users. All bedrooms have private en-suite facilities, which are furnished to a good standard, with a call system. A television point and telephone point are optional to every room. Arts and craft, library, hairdressing, payphones, laundry and a private post box are all made available to service users. The home has its own mini-bus for outings and social events. All meals are prepared and cooked on the premises. A flexible menu is planned and served each day and the cook is able to cater for any individual specialised meals or dietary requirements. Visitors are welcome at any time and while they are visiting they are offered complimentary beverages. Should visitors wish to stay for a meal, they are welcome to do so. Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 10th November 2005 by one inspector. The purpose of the inspection was to ensure the home continues to provide a good standard of care for its residents. The Registered Manager was on duty and made her self-available throughout the inspection. Residents, visitors and staff present at the visit were made aware of the inspection through discussion with the inspector. They were invited to give their views on the care and services provided. Comment cards/questionnaires were left for residents, visitors and other professionals, thereby giving the opportunity for anonymous feedback. Records were inspected and these included resident’s care plans. What the service does well: What has improved since the last inspection? The home continues to strive in improving the quality of care for residents and the atmosphere in the home is good. Formal staff supervision has started taking place. Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 6 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. Mount St Joseph`s Home DS0000001360.V262207.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 Mount St Joseph`s Home DS0000001360.V262207.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): None of these standards were assessed at this visit. EVIDENCE: Mount St Joseph`s Home DS0000001360.V262207.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): 7,8,9,10. Residents are treated with respect and their privacy is upheld. Medication administration records were good. The care plans inspected contain relevant information including healthcare needs. However reviews have not always taken place. Residents stated they were happy with the care offered and all appeared well dressed and comfortable. They felt assured that they were treated with respect and that their privacy and dignity was respected. EVIDENCE: Case tracking was done for several residents which involved looking at their care records and medication charts. The care plans provided some good information about how care needs were met. However there were some areas where improvements could be made in relation to keeping to dates of reviews. Medication ordering and administration systems were looked at. Detailed records show the medication ordered and received for each resident. Administration charts are well completed. During the visit staff were observed maintaining the dignity and privacy of residents at all times. All residents appeared well dressed. Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 10 Residents said they were well looked after and described the staff as “very good” “kind” and “helpful”. Several resident said staff were quick to respond if she needed help. Mount St Joseph`s Home DS0000001360.V262207.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): 12,13,14,15. Overall, residents expressed contentment with the quality and quantity of the food. Visitors are welcomed to the home at any time. This encourages a regular flow of family and friends to the home, so enjoyed by the residents. Residents are happy with the activities provided and in which the home assists them to maintain contact with family and friends. EVIDENCE: The relative spoken with during the visit to the home said everyone is made welcome and they can ask and are kept up to date of any changes. It was good to note that all staff in the home responded to the residents and were seen to offer reassurance and assistance. The overall feedback from residents was that they were happy with the meals that were provided. It was notice on residents’ files nutritional needs are not routinely assessed. Resident had the opportunity to sit and have their meals in a well-presented dining area. Staff interacted well with the residents while assisting them to the table. Residents stated they were happy with the leisure provision provided by the home. A list of activities uses to be placed on the notice board for residents and family to see this appear to have stopped. There are excellent garden facilities at the front and rear of the home. Residents said that they were given Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 12 choices such as what time they got up and went to bed, what they had for their meals and what clothes they wanted to wear. Mount St Joseph`s Home DS0000001360.V262207.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): 16,18. Residents and relatives feel confident that their complaint would be dealt with. Staff had an understanding of adult protection, however they must have adult protection training if they and residents are not to be at risk. EVIDENCE: Residents and relatives said they felt confident that their complaints would be dealt with seriously. The appropriate policies and procedures were seen to be in place with all the relevant details. Talking to staff on the day it was evident they are all clear on their responsibility about reporting any allegations of abuse. However from checking the training records there are some staff that has not yet had adult protection training to ensure they and residents are not at risk. The home has not received any formal complaint since the last inspection. Mount St Joseph`s Home DS0000001360.V262207.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): 19,20,21,23,24,25,26. The environment in and around the home is well maintained, which provides a safe environment for residents and staff. EVIDENCE: The layout of the home appears suitable for its stated purpose. It was clean and well maintained. There is call bell system in place, which was tested, and this was answered in good time. Residents said they did not have to wait long when they used the call bell. The home is decorated and furnished to a good standard throughout and the communal rooms offer a safe and comfortable space for the residents. Staff were seen to knock on doors before entering residents bedrooms. The domestic member of the staff team told how she manages her workload to ensure the home is kept clean and tidy, which it was on the day of the inspection. Mount St Joseph`s Home DS0000001360.V262207.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): 27,30. The number and skill mix of staff appear sufficient to meet the needs of the residents. However some training around adult protection is required. All staff were very pleasant during the inspection. EVIDENCE: Staffing level appeared to meet the needs of residents. Those staff spoken with said they are able to access any relevant training courses and are encouraged to do the NVQ level 2 qualification awards, however many stated they would like to advance to NVQ level 3 awards with the support from the home. Several staff have not had adult protection training. All staff were very pleasant and appeared to be communicating well with residents and their relatives. Mount St Joseph`s Home DS0000001360.V262207.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): None of these standards were assessed at this visit. EVIDENCE: Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 17 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 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 4 4 4 x 4 4 4 3 STAFFING Standard No Score 27 3 28 X 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 18 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. 2 Standard OP15OP7 OP30OP18 Regulation 15 18 Requirement Care plan reviews must be done for all residents and nutritional needs routinely assessed. Adult protection training is required if residents and staff are not to be put at risk. Timescale for action 02/02/06 01/04/06 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 12 Good Practice Recommendations A weekly or monthly list of activities should be placed on notice boards throughout the home. Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Mount St Joseph`s Home DS0000001360.V262207.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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