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Inspection on 31/10/05 for Presentation Sisters Care Centre

Also see our care home review for Presentation Sisters Care Centre for more information

This inspection was carried out on 31st October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Residents and visitors spoken with were generally pleased with the home, the standards of care, and the staff. Positive comments were made, such as "The staff are very kind" and "The staff understand my Mum`s needs". Staff spoken with liked working at the home and were knowledgeable about the individual needs and preferences of residents. Meals in the home were of a high standard and attractively presented. There was an activities programme in the home offering a range of social activities to residents. The home had a calm, relaxed atmosphere and appeared well organised. Staff training was a high priority at the home.

What has improved since the last inspection?

Improvements had continued to residents care records, including evidence of monthly reviews of care plans.

What the care home could do better:

Further work was needed to ensure that residents or their representatives were consulted and involved in care planning and reviews, and to document this. The activities programme should be expanded so that more of the residents could be offered activities, particularly one-to-one activities. The training records need to include records of individual staff training carried out to ensure staff are properly supported to do their jobs.Further development of the quality assurance and staff supervision systems was needed. This would ensure that the home was listening to the views of residents, their representatives, staff, and others involved in the home.

CARE HOMES FOR OLDER PEOPLE Presentation Sisters Care Centre Chesterfield Road Matlock Derbyshire DE4 3FT Lead Inspector Rose Veale Unannounced Inspection 31st October 2005 10:00 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 Presentation Sisters Care Centre DS0000002072.V260519.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. Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Presentation Sisters Care Centre Address Chesterfield Road Matlock Derbyshire DE4 3FT 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) 01629 582953 01629 55140 The Presentation Sisters Mrs Linda Joyce Monk Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow Presentation Sisters to accommodate one named individual under 65 (named in notice of proposal) 6th July 2005 Date of last inspection Brief Description of the Service: The Presentation Care Centre is situated on the outskirts of Matlock, where a range of local amenities and public transport are available. The home provides personal and nursing care for up to 36 residents. Residents are all accommodated in single rooms on three floors of the home. Only one room is en suite, but there is ample provision of bathrooms and toilets. The home is fully accessible for residents and well maintained. There are extensive grounds to the home with magnificent views over local countryside. The home is attached to the Presentation Sisters Convent, but operates independently. Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5½ hours on one day. There were 35 residents accommodated in the home on the day of the inspection, including 26 residents assessed as needing nursing care. Residents, visitors and staff were spoken with during the inspection. The care records of four residents were examined, plus other records related to the staffing and management of the home. The manager was available and very helpful throughout the inspection. It was noted that the draft inspection report from the previous inspection on 6/7/05 was not received by the home and so the providers did not have the opportunity to respond to the requirements made in that report before final publication. What the service does well: What has improved since the last inspection? What they could do better: Further work was needed to ensure that residents or their representatives were consulted and involved in care planning and reviews, and to document this. The activities programme should be expanded so that more of the residents could be offered activities, particularly one-to-one activities. The training records need to include records of individual staff training carried out to ensure staff are properly supported to do their jobs. Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 6 Further development of the quality assurance and staff supervision systems was needed. This would ensure that the home was listening to the views of residents, their representatives, staff, and others involved in the home. 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. Presentation Sisters Care Centre DS0000002072.V260519.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 Presentation Sisters Care Centre DS0000002072.V260519.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): EVIDENCE: These standards were not assessed at this inspection. Of the key standards, Standard 3 was assessed and met at the last inspection and Standard 6 does not apply to this service. Presentation Sisters Care Centre DS0000002072.V260519.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 and 9 The health and personal care needs of residents appeared well met, although there was a continuing lack of consultation with residents / their representatives in care planning and review. The systems in place for the administration of medication ensured the safety and welfare of residents. EVIDENCE: The care records of four residents were examined. It was a requirement at the last inspection that care plans must be reviewed at least monthly and also that residents and / or their representatives must be involved in the planning and review of care. All the care plans seen had been reviewed monthly and updated as required and the requirement had therefore been met. No evidence was seen of the involvement of residents and the requirement has been carried forward in this report. The care records were generally well organised and care plans covered all the assessed needs of residents. Medication in the home was administered using a monitored dose system. The home’s policy and procedures regarding medication included all the information required and had been recently updated to include the new system for disposal Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 10 of drugs. The medication administration records, (MARs), were seen. The MARs were correctly completed and included a record of medication received into the home and medication disposed of. Separate records were also kept of medication disposed of. Some MARs had handwritten entries which were not signed by the person writing them or countersigned by another person checking the entry as correct. Medication was correctly and securely stored. Presentation Sisters Care Centre DS0000002072.V260519.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 and 15 Residents were offered a good range of activities to meet their social and spiritual needs. The meals provided in the home were of a high standard ensuring that residents were offered appealing and wholesome choices. EVIDENCE: Most of the residents spoken with had chosen the home because they felt their spiritual needs would be met. One resident was pleased to be able to attend mass every week. There was a programme of activities offered to residents in the home, organised by two part-time activities coordinators working approximately 12 hours per week in total. The activities staff were enthusiastic about their role and knowledgeable about the preferences of residents. Records were seen of the activities carried out and these included playing dominoes, music and exercise, reading, and crafts. There was a weekly ‘trolley shop’ where residents could buy toiletries, sweets etc. The records noted which residents joined in and what the response to the activity was. One resident spoken with enjoyed the activities offered. Staff spoken with felt that the activities programme was good and that it should be expanded. Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 12 Residents and visitors spoken with said the meals in the home were of a very good standard, varied and appetising. The home had a large, well equipped kitchen which also catered for the convent. The kitchen was clean and well organised. There was a four week menu with a choice of main courses and a vegetarian choice every day. The menu was varied and appeared well balanced. There was evidence that residents were encouraged to comment on the meals and that their suggestions and preferences were taken into account when planning the menus. Lunchtime was observed in two of the dining areas. The meals were attractively presented, including liquidised meals. There was a quiet, relaxed atmosphere with staff helping residents in an unobtrusive way. Presentation Sisters Care Centre DS0000002072.V260519.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 robust complaints procedure ensured that residents / their representatives could be sure their complaints were taken seriously and acted on promptly. EVIDENCE: The complaints procedure for the home was seen and this contained all the required information. Two residents spoken with said they were happy to discuss any problems with staff and felt confident hat their concerns would be acted on. Visitors spoken with were aware of the complaints procedure but had not had to use it. One visitor said that any concerns were raised with the staff and action was always taken promptly. There was a complaints book with records of complaints made, action taken and the outcome of the complaint. Presentation Sisters Care Centre DS0000002072.V260519.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): EVIDENCE: These standards were not assessed at this inspection. The key standards 19 and 26 were assessed and met at the last inspection. A full tour of the building was not carried out at this inspection, but the areas seen were clean and pleasant. Presentation Sisters Care Centre DS0000002072.V260519.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): Staff were well supported by the programme of training in the home. EVIDENCE: Although standard 29 was not fully assessed at this inspection, a requirement made at the last inspection was followed up. The requirement was that proof of identification, including a recent photograph, must be provided for all staff employed at the home. This requirement had not been met and therefore is carried forward in this report. The staff training records were examined. It was clear that there was a programme of staff training in place including induction, NVQ, moving and handling, fire safety, basic food hygiene, infection control, first aid, and dementia awareness. Individual records for staff were in place but had not been completed. Staff spoken with said that training was a high priority at the home and confirmed that they had attended training as recorded. They said the training was useful and relevant to their job roles. Presentation Sisters Care Centre DS0000002072.V260519.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): 38 The health and safety of residents and staff were promoted and protected by the home’s policies and procedures, the systems in place and staff awareness and attitudes. EVIDENCE: Standards 33 and 36 were not fully assessed at this inspection, but a requirement and a recommendation made at the last inspection were followed up. Neither had been met and so are carried forward in this report. It was clear from the evidence seen that the home took reasonable measures to ensure the health, safety and welfare of residents and staff. The evidence included: records of accidents and incidents in the home; records of fire alarm tests, fire drills, maintenance of fire safety equipment; checks of hot water temperatures; measures taken to control the risk of Legionella; risk assessments of working practices; and the home’s policies and procedures Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 17 regarding health and safety issues. Staff spoken with showed a good awareness of health and safety issues and how to minimise risks to residents and staff. Presentation Sisters Care Centre DS0000002072.V260519.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 3 Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1)(2) Timescale for action Care plans must be prepared and 31/01/06 reviewed in consultation with residents or their representatives. Proof of identification, including 31/01/06 a recent photograph, must be provided for all staff employed at the home. Individual records must be kept 31/01/06 of all training undertaken by staff. A formal system of quality 31/03/06 assurance must be introduced. Original timescale 30/03/05 Requirement 2 OP29 19(1)(b) (i) 17(2) 24(1)(2) (3) 3 4 OP30 OP33 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 OP9 Good Practice Recommendations Handwritten entries on Medication Administration Records, (MARs) should be signed by the person making them and then countersigned by the person checking the entry as correct. DS0000002072.V260519.R01.S.doc Version 5.0 Page 20 Presentation Sisters Care Centre 2 3 OP12 OP36 Consideration should be given to increasing the hours worked by the activities staff so that the activities programme offered can be expanded. Care staff should receive formal supervision at least six times per year. Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Presentation Sisters Care Centre DS0000002072.V260519.R01.S.doc Version 5.0 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!