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Inspection on 29/07/05 for Mount St Joseph`s Home

Also see our care home review for Mount St Joseph`s Home for more information

This inspection was carried out on 29th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager makes sure that people who move into the home are properly assessed and receive information about the home. The staff treats people with respect, and are caring and friendly. The manager ensures residents are kept in a safe, clean and pleasant environment. Members of staff spoken with felt they have a good staff team who work well together. Several relatives/visitors were spoken with and they were all very complementary about the care given at Mount St Joseph`s.

What has improved since the last inspection?

The home continues to improve and identify the way in which resident`s needs should be met. The manager of the home is suitably experienced for this post. She has successfully completed the Commission for Social Care Inspection registration process.

What the care home could do better:

All staff should receive regular recorded supervision, in addition to regular contact on day-to-day practice and yearly appraisal.

CARE HOMES FOR OLDER PEOPLE Mount St josephs Shire Oak Road Leeds West Yorkshire LS6 2DE Lead Inspector Hebrew Rawlins Unannounced 29th July 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. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mount St Josephs Address Shire Oak Road Leeds LS6 2DE 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) 0113 2784101 0113 2305127 The Little Sisters of the Poor Sister Kathleen Veronica Mc Mahon Care Home with Nursing 46 Category(ies) of Old age (46) registration, with number of places Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10/3/05 Brief Description of the Service: Mount St. Joseph’s 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 josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 29th July 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. Service users 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. Records were inspected and these included resident’s care plans and staff recruitment files. What the service does well: What has improved since the last inspection? The home continues to improve and identify the way in which resident’s needs should be met. The manager of the home is suitably experienced for this post. She has successfully completed the Commission for Social Care Inspection registration process. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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 josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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 Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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) 1,2,3,4,5. The home has a good pre and admission procedure in place. People are able to make an informed decision about the home the written information they receive and from what they are able to see on their visit to the home. All residents receive a contract of terms and conditions of the home. EVIDENCE: A copy of the Service user guide which all prospective residents is given was seen and was found to contain sufficient information to enable the person to make an informed choice about the home. Copies of the terms and conditions of the home were seen in individual files and contained all the appropriate information. The pre admissions assessments were in the residents’ files and were seen to be very comprehensive, containing sufficient information for staff to know what the needs of people were. Residents spoken with confirmed that they or their family had visited the home prior to their admission. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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) 8,9,10. Care plans are in place for all residents and contain relevant information including healthcare needs. Staff are aware of the residents’ needs and there is good communication amongst the staff group. Resident stated they were happy with the care offered and all appeared well dressed and comfortable. EVIDENCE: Residents said their needs were well met and staff looked after them very well. They stated nothing was too much trouble for most of the staff, this was also confirmed by relatives visiting. During the visit staff were observed maintaining the dignity and privacy of residents at all times. Medication records were seen and found up to be up to date signed and the storage of medication was satisfactory. Records showed visits by GPs and other healthcare professionals were clearly recorded and included the reasons for the visit and any actions required. Care plans examined contained the needs of the residents and what tasks were required to be done in order for staff to meet these needs. There was evidence available to show that the plans are reviewed and updated on a regular basis. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 10 Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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) 12,13,14,15. Residents are given opportunities to choose how they spend their time. Social activities are offered but could be increased. Staff encourage resident to maintain contact with family/friends where possible and visitors are welcome at the home. The atmosphere in the home was good. Menus showed a varied, nutritious diet taking into account individual choices. EVIDENCE: Residents who are able are free to come and go as they wish; this was confirmed in discussion with them. They also stated that they can go to bed/get up at the times they choose and the meals at the home are very good. The meal served to residents was seen to be presented well and nutritious in content. Staff were seen to offer residents appropriate help to ensure they were able to enjoy their meal. A list of activities is placed on the notice board for residents and family to see. Staff and residents participated in verbal banter and the social atmosphere was good. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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) 16,18. The home provides clear information on how to make a complaint about the service. It includes reference to the Commission for Social Care Inspection if people want to take a complaint outside the home. EVIDENCE: The appropriate policies and procedures were seen to be in place. Residents and relatives visiting said they would talk to the manager if they have any worries. No complaints are recorded since the last inspection. In discussion with staff, they are all clear on their responsibility about reporting any allegations of abuse. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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) 19,20,23,24,25,26. The home offers a good of safety and comfort for its residents. It is decorated and furnished to a good standard with resident able to access the garden areas easily if they so choose. EVIDENCE: Residents are encouraged to bring their own possessions with them on admission and their bedrooms are comfortably furnished. The rooms offer sufficient space to ensure residents can follow their own lifestyles and staff were seen to knock on doors before entering. The home is decorated and furnished to a good standard throughout and the communal rooms offer a safe and comfortable space for the residents. All areas of the home were clean and tidy. Residents have access to a wellmaintained garden, which is well used. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 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. The home appears to have a robust recruitment procedure in place to ensure suitable staff are employed. There was sufficient staff on duty at the time of the inspection and skill mix was appropriate. Staff can access training easily and are encouraged to do so. EVIDENCE: Staff files were seen at the time of the inspection and they showed written references and CRB checks are obtained before staff starts working at the home. Staff spoken with said they are able to access any relevant training courses and are encouraged to do the NVQ awards and are given assistance to complete these. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 15 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) 31,32,36,37,38. The staff confirmed that the manager offer excellent support and make herself available to discuss any issues that may arise. Yearly appraisal takes place however formal supervision is required at least six times per year and recorded. EVIDENCE: Speaking with residents their relatives and staff it was clear that they feel the manager offers excellent support and is always prepared to listen to them. Everyone spoken with felt that they could approach her if they had a problem/concern. However staff do not receive regular recorded supervision, in addition to regular contact on day-to-day practice. Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 16 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 4 x x 4 4 4 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 2 3 3 Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 17 no 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 36 Regulation 18 Requirement All staff members should receive recorded supervision at least six times per year. Timescale for action 1/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Mount St josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 18 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 josephs J52 J03 S1360 Mount St Josephs V232753 280705 Stage 4.doc Version 1.30 Page 19 - 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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