Inspection on 06/07/05 for Presentation Sisters Care Centre

This inspection was carried out on 6th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Presentation Sisters Care Centre 28/08/07

Presentation Sisters Care Centre 30/01/07

Presentation Sisters Care Centre 31/10/05

Presentation Sisters Care Centre 26/05/04

Presentation Sisters Care Centre 01/10/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE PRESENTATION SISTERS CHESTERFIELD ROAD MATLOCK DERBYSHIRE DE4 4FT Lead Inspector Rose Veale Unannounced Inspection 6th July 2005 09:30am 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. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Presentation Sisters Care Centre Address Chesterfield Road Matlock Derbyshire DE4 3FT 01629 582953 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) The Presentation Sisters Mrs Linda Monk Care Home with Nursing 36 Category(ies) of OP registration, with number of places PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: To allow Presentation Care Centre to accommodate one named individual under 65 (named in notice of proposal) Date of last inspection 24/11/2004 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 C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5 hours on one day. The registered manager and administration manager were available and helpful throughout the inspection. There were 36 residents accommodated in the home on the day of the inspection. Residents, visitors and staff were spoken with and a tour of the building was undertaken. The care records of five residents were examined, plus other records relating to the staffing and management of the home. A pre-inspection questionnaire had been completed by the home and was given to the inspector on the day of the inspection. What the service does well: What has improved since the last inspection? The home had continued to improve care records by using new documentation. The registered manager had achieved the Registered Manager’s Award. The home had started working towards achieving the Investors in People Award. The home had started to develop a quality assurance system and a staff supervision system. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 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. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 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 PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 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 and 4 Comprehensive assessment information was obtained to ensure the home could meet residents’ individual needs. EVIDENCE: The care files of five residents were examined. The home had started to use new documentation which was clear and well organised. Assessment information covered appropriate areas, such as moving and handling, nutrition, help with personal hygiene, risk of developing pressure sores, social needs and personal history. A care plan had been produced for each file seen. Assessments had been regularly reviewed. The manager said that an assessment of the needs of prospective residents was always carried out to ensure that the home could meet their needs. The relatives of a recently admitted resident confirmed that an assessment had taken place prior to the home offering admission. Staff spoken with felt that the home was able to meet the needs of residents. Several residents were members of the order of Presentation Sisters and other residents had chosen the home because they felt it would meet their spiritual PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 9 needs. One resident spoken with was pleased that she was able to attend a daily mass held in the convent chapel. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 10 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 and 10 Residents’ health and personal care needs appeared to be well met, with good liaison with other healthcare professionals and evidence of respecting residents’ privacy and dignity. However, lack of participation of residents or their representatives in care planning meant they were not fully involved in their plan of care. EVIDENCE: The home had almost completed changing all care plans to the new documentation, as required at the last inspection. The care plans of five residents were seen and these were all in the new documentation. The care plans were well written and clear on the action required by staff to meet the needs of residents. The care plans covered areas appropriate to the individual needs of residents, such as continence, nutrition, personal hygiene, mobility and mental health. One out of the five care plans seen was signed by a relative of the resident. There was no evidence of the involvement of the resident or their representative on the other care plans. Although care plans specified a monthly review interval, there was no record that reviews had taken place. In discussion with the relative of a resident, the manager and a care assistant acting as keyworker, it was clear that care plans were being reviewed regularly, but reviews were not documented. Assessments had been reviewed regularly, though not always monthly. The manager agreed that PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 11 assessments such as risk of developing pressure sores, nutrition, moving and handling, and personal risk assessments should be reviewed and updated monthly along with the care plans. The care files contained records of visits and treatment by the resident’s GP, and also of other health care professionals, such as optician, dentist or chiropodist. A resident spoken with said that she had recently been seen by an optician visiting the home and she was pleased with the service and with her new glasses. Residents and relatives spoken with said that staff treated residents with respect and upheld their dignity. Residents spoken with said that staff always knock on doors before entering and this was observed during the inspection. Staff spoken with were aware of the need to protect the privacy and dignity of residents. Residents said that staff addressed them in their preferred manner. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 12 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) 13 and 14 The policy of the home and staff attitudes ensured that residents were able to maintain contact with family and friends. However, there was not sufficient information on access to advocacy services. EVIDENCE: The home had an open visiting policy and visitors in the home on the day of the inspection confirmed that they were able to visit at any reasonable time. Visitors spoken with said they were made welcome by staff and were able to see their relative in private if they wished. A resident spoken with said she was able to maintain contact with friends and usually saw visitors in her room. Information about visiting the home was included in the service user’s guide. There was no information in the home about local advocacy services, although the service user guide said that staff would be willing to arrange this for residents. The manager said that residents records would be made available to them if they asked. The service user’s guide could be updated to include this information with reference to the Data Protection Act and the Freedom of Information Act. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 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 standard(s) 18 Residents in the home were protected from abuse by staff awareness and by the home’s policies and procedures. EVIDENCE: Residents and staff spoken with said they were happy to bring any concerns to the manager or to senior staff. The adult protection policy in the home included reference to the Derbyshire multi-agency procedures. Recruitment procedures in the home included obtaining a Criminal Records Bureau disclosure and records that these had been obtained were seen. The home dealt with personal money for some residents so that they had cash available for buying personal items or for hairdressing. The money was kept securely and clear records were seen of all transactions. The home’s policy stated that residents could have access to their own money records with seven days notice. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 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 standard(s) 19, 21, 24 and 26 The home was clean, comfortable and well maintained providing a pleasant environment for residents. EVIDENCE: The home was a large building which had been changed and added to over many years. There were extensive, well maintained grounds and good views over the local countryside. The home was accessible for residents with two passenger lifts, wide corridors for wheelchair access and handrails throughout. The building appeared well maintained and in good decorative order. The home was well provided with bathrooms, showers and toilets. Bathrooms were roomy and well equipped to meet residents needs with grab rails, bath hoists, shower seats, and assisted baths. Toilets had grab rails and raised seats. The bedrooms seen were clean, pleasant and comfortably furnished. Residents had brought their own possessions and furniture to personalise the rooms. A PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 15 resident spoken with was happy with her room and said “it feels like home”. Relatives spoken with were pleased with the rooms provided. The home was clean and free from offensive odours on the day of the inspection. The laundry room was spacious and well equipped. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 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 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, 28 and 29 Staffing levels in the home ensured that the needs of residents could be met. Staff records did not contain all the information required to fully protect residents. EVIDENCE: The staff rota indicated that there were sufficient staff on duty. Staff spoken with felt that staffing levels in the home were generally good, but did not like reliance on agency staff when permanent staff were unavailable. Residents and relatives spoken with felt that there were enough staff on duty in the home. A new member of staff said that she had been supernumary for her first two weeks and so had been able to shadow a more experienced member of staff. On the day of the inspection, the new member of staff was working with an experienced member of staff who had been at the home for several years. Three staff files were seen. These contained records including application forms, interview notes, references, medical forms and records of appraisal. Two of the files seen only contained one written reference. None of the files had a photograph of the member of staff or proof of identity. The home supported staff to undertake NVQ training and more than 50 of the care staff had achieved NVQ Level 2 or above. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 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 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, 33, 36 and 37 The home was generally well managed and well organised. However, quality assurance and staff supervision systems were not appropriately developed to fully ensure the home was run in the best interests of residents. EVIDENCE: The registered manager and the administration manager worked together to cover all aspects of running the home. The administration manager had responsibility for ancillary and non-nursing services, maintenance issues and finance. The registered manager was qualified, competent and experienced to run the home. She had recently completed the Registered Manager’s Award. It was clear that the two managers enjoyed a good working relationship which had a positive effect on the running of the home. Residents, visitors and staff spoken with were positive about the management of the home and felt the registered manager was open, approachable and dealt effectively with any problems. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 18 At the last inspection it was a requirement that a formal system of quality assurance must be introduced and some work had been carried out towards this. A policy was available and a questionnaire was being devised. The registered manager said that the recent appointment of a deputy matron would allow her to have more ‘office’ time to develop the quality assurance system. The home has recently started working towards achieving the Investors in People award. It was a requirement at the last inspection that the system of formal recorded supervision should cover all care staff. Some work had been done towards this. The managers and some of the registered nurses had undertaken training in the supervision and appraisal of staff. A policy had not been developed. Supervision sessions were taking place, though not six times per year as recommended. One member of staff spoken with had recently had a supervision session and said she found this very useful. Records in the home were generally good, well organised and securely kept. There were gaps in the care records and staff records as identified under Standards 7 and 29. PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x 3 x 3 2 2 x PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 20 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. 2. Standard 7 7 Regulation 15(1)(2) 15(1)(2) Requirement Care plans must be reviewed at least monthly Care plans must be prepared and reviewed in consultation with service users or their representatives Two written references must be obtained for newly recruited staff Proof of identification, inlcuding a recent photograph, must be obtained for all staff employed at the home A formal system of quality assurance must be introduced. Original timescale 30/03/05 Timescale for action 31/08/05 31/08/05 3. 4. 29 29 19(1)(b) (i) 19(1)(b) (i) 24(1)(2) (3) 31/10/05 31/10/05 5. 6. 33 31/10/05 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. 2. Refer to Standard 14 36 Good Practice Recommendations The home should provide more information on local advocacy services and information about residents access to personal reocrds Care staff should receive formal supervision 6 times per year C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 21 PRESENTATION SISTERS PRESENTATION SISTERS C52 CO2 S2072 Presentation Sisters V235817 060705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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. 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