Inspection on 10/05/07 for St Angelas Convent

This inspection was carried out on 10th May 2007.

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

St Angelas Convent 09/01/08

St Angelas Convent 11/05/06

St Angelas Convent 02/02/06

St Angelas Convent 14/06/05

St Angelas Convent 05/12/04

St Angelas Convent 06/07/04

St Angelas Convent 10/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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 St Angelas Clifton Down Convent St Angelas Clifton Down Convent 5 Litfield Place Clifton Bristol BS8 3LU Lead Inspector Sandra Gibson Unannounced Inspection 10th May 2007 10:45 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 St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 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. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Angelas Clifton Down Convent Address St Angelas Clifton Down Convent 5 Litfield Place Clifton Bristol BS8 3LU 0117 9735436 0117 9706844 stangelas@btconnect.com 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) Sisters Of The Temple Sister Marie Louise Levern Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: St Angelas Clifton Down Convent is operated by The Sisters of The Temple, a Roman Catholic religious order. The manager and three of the senior care staff are sisters within the order. Additional lay staff are employed to fulfil care and ancillary responsibilities. It is registered by the Commission for Social Care Inspection to provide accommodation and personal care to 23 persons aged 65 years and over. St Angelas is a large detached building in a suburb of North Bristol close to the countryside. Shops and community facilities are within 1/4 mile of the home. Accommodation is provided over three of four floors, in single rooms, all of which have en-suite facilities. There is a communal dining room on the ground floor, which is only used on special occasions by residents. There are no communal lounge facilities in the home. St Angelas home offers respite care when places are available. A shaft lift is in place to all floors. The top floor offers accommodation to independent guests of the Sisters of the Temple. The range of fees is between £470 and £507 per week and extra charges are made for chiropody, hairdressing, etc. Currently this information is initially only provided verbally prior to admission and then confirmed in writing within a new resident’s contract. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key or main inspection carried out over one day (unannounced). The visit was to follow up requirements and recommendations made at the last key inspection held on the 11th May 2006, the random unannounced inspection 26th January 2007 and an unannounced visit to the home on the 9th March 2007. The unannounced visit was carried out to focus on an anonymous concern made about a resident who was alleged to have not seen a GP for a few days and was sent to hospital four days after an accident, Prior to this visit to the home a survey had been sent to all residents and their relatives by the Commission for Social Care Inspection. Comments from the responses to the surveys are included in the report. Information was also gathered from: examining previous correspondence with the home, inspection reports, information from pre inspection questionnaire. A range of records was looked at during the visit, which included: a sample of care records, staff records, policies and procedures. A number of people who live in the home and staff employed at the home were spoken with during this visit. The manager and deputy manager were also present. What the service does well: The care provided to residents of St Angela’s is of a high standard. The staff ensure that residents have their individual needs met with privacy, dignity and respect both when they are alive and at the time of their death. Future training has been planned in holistic care, which should support staff further in their work. Residents benefit from living in a safe, comfortable, homely environment. The omplaints procedure in place in the home is satisfactory. The arrangements in place ensure that residents and their represenatives are fully aware of how to make a complaint and know they will be listened to. Staffing levels at night and during the day are satisfactory with a result that residents’ needs are met at all times St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 6 There are good systems in place to ensure that residents’ financial interests and valuables are safeguarded by the homes record keeping, policies and procedures. What has improved since the last inspection? What they could do better: The information provided to prospective residents and their representatives prior to admission to the home has been up dated since the last inspection. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 7 This is a great improvement however, it still contains l some misleading information which must be removed to ensures that people have the full information they need to make an informed choice about where to live The admission procedure has improved greatly since the last two key inspections, but it is still not wholly satisfactory as it does not ensure that all individual needs have been fully assessed prior to moving into the home. Without this information there is no assurance that an individual’s needs can be met. The opportunity to review the suitability of the home for new residents has improved since the last inspection but further improvement must take place so that the potential for unplanned admissions are avoided. There have been great improvements in the care planing system since the last three key inspections. Further work is needed however to ensure that care plans are completed on time to ensure that residents’ individual needs are fully identified. 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. The summary of this inspection report can be made available in other formats on request. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 8 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 St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, 5, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided to prospective residents and their representatives prior to admission to the home has been up dated since the last inspection. This is a great improvement however, it still contains some misleading information which must be removed to ensures that people have the full information they need to make an informed choice about where to live The admission procedure has improved greatly since the last two key inspections, but it is still not wholly satisfactory as it does not ensure that all individual needs have been fully assessed prior to moving into the home. Without this information there is no assurance that an individual’s needs can be met. The opportunity to review the suitability of the home for new residents has improved since the last inspection but further improvement must take place so that the potential for unplanned admissions are avoided. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 10 EVIDENCE: The statement of purpose and service users’ guide (called the residents guide in this home) were both examined. They were reviewed an up dated in July 2006 following the last key inspection. The statement of purpose and service users guide now refers to the experience and qualifications that staff have achieved and it invites people to look at the list of the staff employed in the home which gives full names of staff, qualifications and experience. This information is held in the offices. The service users guide now refers to information about the fees and extra charges required. This information is also available from the office However the residents’ guide continues to state that one of the aims of the home is to include registered nurse care. This information is misleading to prospective residents and their representatives as St Angela’s is a care home, which is registered to provide personal care and not nursing care. Once again the manger assured the inspector that the staff at St Angela’s does not provide nursing care. If nursing care is needed on a temporary basis this is provided by the district nursing service. The residents guide is now made available at the entrance to the home for prospective residents, their relatives and other representatives to look when visiting the home. The majority of residents are self funding and therefore a needs assessment and care plan are not usually obtained from Social Services and Health prior to a resident being admitted. Following the last two key inspections, the documentation completed when a resident is admitted to the home has improved considerably. However, the information obtained before a decision can be made to whether the home can meet a prospective residents needs or to assess if a residents ‘s needs have also improved since the last key inspection. The manager and two senior care assistants now carry out these assessments. Following an additional follow up visit to the home by the inspector on the 6th December 2006. The manager of St Angela’s’ formally wrote to The Commission For Social Care Inspection to request the removal of the condition that three residents may be accommodated at St Angela’s when the primary focus of their care is as a result of dementia. During the last two inspections the manager has confirmed that there are no residents accommodated at St Angela’s whose primary focus of their care was as a result of dementia. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 11 On this occasion the inspector saw one new resident who had been admitted to the home who had been previously diagnosed with dementia. The manager told the inspector that the care provided to this resident was a result of her being an older person and not because of the dementia, which was quite mild at this stage. The manager said that she was monitoring the situation and would review this residents needs on a regular basis. Prospective residents and their representatives are invited to look around the home before they move in on a trial basis. However, as highlighted at the last key inspection there was no evidence to confirm that the trial period for a permanent placement is being formally reviewed between four to six weeks after admission. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been great improvements in the care planing system since the last three key inspections. Further work is needed however to ensure that care plans are completed on time to ensure that residents’ individual needs are fully identified. The physical healthcare needs of residents continue to be well met with evidence of St Angelas staff having good relationships with health staff. Following the last inspection specialist staff training in working with residents with mental health needs has taken place and further training is planned . This improvement in staff skills now ensures that residents’ mental health needs are met. The medication administration system is now satisfactory. Following improvements in storage the syatem in place ensures that there are safeguards in place to protect residents and staff at all times. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 13 The care provided to residents of St Angela’s is of a high standard. The staff ensure that residents have their individual needs met with privacy, dignity and respect both when they are alive and at the time of their death. Future training has been planned in holistic care, which should support staff further in their work. EVIDENCE: A sample of care plans were seen and a great improvement was found since the last two key inspections. They are written in plain English and give detailed information about the care required for the individual residents. However not all residents had a detailed care plan and this included a new resident who staff said that she had a high levels of needs probably as a result of settling into the home environment. These needs were not identified on the care plan and there was no evidence of a risk assessment in place from the sample of records seen and risk assessed. The daily running records were found to be up to date and there was also evidence to confirm that there are ongoing plans in place to improve the care planning documentation. Some care files do not have photographs of residents in place. The Inspector was informed that arrangements for all residents to have a photograph in place were in hand. There are photographs of residents held on the medication administration record, Records confirmed that health professionals such as General Practitioners, District Nurse and chiropodists are contacted at the appropriate time. Equipment was observed to be in place to prevent pressure sores in residents who were at risk. There are no two residents who are bedfast but none were reported to have pressure sores. During the inspection one resident was visited in her room and she looked comfortable and well supported. There was evidence of regular attention to this resident’s physical needs as well as her emotional needs with privacy and dignity. Comments from visiting health professionals included: “Excellent standard of care is provided”. Evidence confirmed that the majority of staff have received training in dementia care and following the last inspection staff have received training in working with older people with mental health needs. Future training is planned in working with people who suffer with anxiety and depression. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 14 The medication administration system was examined. There was evidence to confirm that the quantity and amount of prescribed medication received into the home is now accurately recorded. A sample check of medication administered was checked all records were noted to be up to date. A few residents continue to be supported to self-administer medication. There are now risk assessments in place to protect these residents. Lockable storage facilities are available in all residents’ rooms. The security arrangements for the storage of controlled medication or medication that needs to be stored, like controlled medication, has improved considerably since the last inspection. All staff involve in the administering of medication have recently received training in medication administration and the storage of medication. Residents seen during the inspection confirmed that they were happy with the support they received and that they were treated with dignity and respect These comments were confirmed in the residents’ surveys and relatives’ comments cards: Residents said, “They are very attentive”. Another resident said, “Everything is at the highest support order. I will have to write a book to put all the remarkable service I receive”. “The staff are always kind and helpful”. Relatives said, “My mother has never been happier. It is a great relief to know that she is so well looked after both physically and all her spiritual needs are catered for. My family are most grateful for the dedication and love shown to my mother in her twilight years.” “I am very happy with the level of care which my mother receives at St Angela’s. I find the staff extremely kind and supportive which I am sure reflects the excellent leadership “. “The care my mother receives at St Angela’s is exceptionally good. She is extremely fortunate to be in such a splendid environment. The nuns are all dedicated and the day staff are also caring, patient and pleasant. I cannot speak highly of this residential home.” Written evidence also confirmed how well residents are cared for when they are dying and their relatives were offered good support during this time. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents of St Angela’s are beginning to benefit from increased opportunities to experience a more stimulating and varied life style which may help to satisfy their individual social, religious, cultural and recreational needs. Visitors are made very welcome and meals are usually well managed and provide daily variation, and good nutrition for people. Further improvement of the catering arrangements facilities must be considered to ensure that the food is not overcooked and residents feel they have enough variety. EVIDENCE: On the whole St Angela’s continues to provide a quiet lifestyle for residents where very few communal activities take place. This is noted to be satisfactory for the majority of residents who are fully informed about the lifestyle prior to admission and this is their preference. Many residents are visited frequently by St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 16 friends and family and may be taken out for the day. Daily mass takes place in St Angela’s Chapel and all residents are made welcome. However, there was information to confirm that despite St Angela’s care home being operated by a Catholic Order of nuns that residents from different religious/ spiritual and cultural backgrounds are admitted to the home and their individual needs are met. Following the inspection conducted in June 2005 a dedicated member of staff now spends more time engaged in social activities with residents on a daily basis. Further progress had been made with developing social activities for residents. The e communal dining room is now being used more frequently for residents to meet. There was written evidence to confirm that seven residents now participate in regular coffee mornings or tea parties. The manager said that following mass families and priests often join in with these events. Written evidence to confirm these social activities are taking place was also available in the residents’ surveys. “I love the coffee mornings and all what goes on in the home; music/piano entertainment / carols etc.” “I love the coffee morning” “Activities are arranged, but I find it very hard to take part because I am stone deaf and find it hard to talk to people”. “There are activities but I prefer not to take party” “I like and enjoy the coffee morning s very much. It is an opportunity to talk to people, to meet new faces and to be happy. I am contented at St Angela’s”. There is not a communal sitting room, but the chapel is always open – sometimes there are musical events and talks. It must be remembered that this is a convent as well as a care home and most of the residents are very elderly and prefer visits from friends and relations a fairly quiet life. Relatives confirmed that they were always made welcome in the home. Comments such as: “I would say that we are welcomed here as a member the extended family and are always made to feel at home. It is a delight to have such a warm and caring community in which to have a relative”. “Every day my mother attends a religious services which is very important to her” Two visitors spoken to during the inspection confirmed they were always made very welcome in the home and that the manager and staff were very helpful. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 17 The inspector sampled the lunch menu that day and noted that the meal was wholesome and nutritious. The evening meal also looked appetising and well presented. Daily menus were also examined and they confirmed that variety and choice were available. This was confirmed in the majority of residents’ surveys. Comments received from residents included: I eat everything that is put before me. The presentation is excellent. I cannot think of anything that could be improved”. “The food has improved in the two years that I have been here”. On the whole meals are good. Varied and there are special days – birthdays etc when the chef or the cook on duty gives extra treats However there were a couple of comments such as “The food is good. At times I feel I could do with more variety”. “Sometimes the meals are overcooked –possibly because they have been in a hot plate for too long. The menus and variety of food is excellent – especially the puddings”. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The complaints procedure in place in the home is satisfactory . The arrangements in place ensure that residents and their represenatives are fully aware of how to make a complaint and know they will be listened to Systems in place to ensure that residents are protected from abuse have improved since the last random inspection. The systems now in place should ensure that residents are protected from risk of harm. EVIDENCE: Information about how to make a complaint is available for visitors where they sign in the visitor’s book at the entrance to the home. The information is also available on each floor of the home. It is also in the resident’s guide. Residents spoken with during the inspection confirmed that they knew the procedure for making complaints and would approach the manager. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 19 Comments received from residents included: “I can always speak to Sister.” I would speak to Sister or one of the nuns on each floor is ready with help or advice. I personally have never felt unhappy about being here, but I have often felt encouraged and up lifted when there have been any anxieties in my outside life. The sisters give great care to their residents”. “I have never had any complaints”. There was one anonymous complaint received at the home by The Commission for Social Care Inspection since the last inspection. The complaint was about a resident who was not seen by her GP for a few days and was sent to hospital four days after an accident in the home. A random visit took place on the 9th March 2007. A safe guarding adults meeting was called and the manager of the home accepted that she should have acted more quickly. One resident spoken to said, “We are well looked after here. Staff are very nice and we have nothing to complain about”. Relatives’ surveys confirmed this information: There is a whistle blowing policy in place in the home for or staff to follow if they have any concerns about poor practice. There is an Adult Protection policy and procedure in place in the home, which complies, with the Local Authority Adult Protection Procedure (No Secrets in Bristol). The majority of staff and the manager have now attended safe guarding adults training following a requirement made at the last inspection. The Commission for Social Care Inspection receive regular notifications about residents’ welfare and health. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, comfortable, homely environment. EVIDENCE: During the course of the inspection the inspector completed a tour of the communal areas and had the opportunity to view the garden space and several residents, rooms. The gardens of St Angels are very attractive and are well maintained. Residents may access the gardens located at the front or rear of the house. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 21 There is a lift facility and ramp facility for wheel chair users to use the rear garden and front gardens The communal areas were found to be clean, smelt fresh and were well maintained. Records confirmed that arrangements for cleaning the home on a regular basis are very good. Minor maintenance work is dealt with immediately. However, the manager formally requests major work and records are maintained of the programme of work including refurbishment, decoration and safety checks. Records confirmed that arrangements were in place for residents to have access to the equipment and adaptations they were assed as needing by health professionals. All residents’ rooms seen during this inspection were found to be safe comfortable and homely and residents confirmed that they could bring items of their own furniture if they chose to. Comments received from residents included: The cleaning lady cleans my room daily. The laundry is returned the same day fresh and clean. “The cleaners who are mostly come through an agency are good regular and trustworthy and because I have been here a long time I have become good friends.” “The general care and comfort at St Angela’s is of the highest possible standard” “My room is cleaned every day” St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,39 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels at night and during the day are satisfactory with a result that residents’ needs are met at all times The procedures for the recruitment of staff have improved considerably since the last inspection, which protects residents from risk of harm. The staff training programme is on the whole satisfactory. The training arrangements in place now ensure that staff have the skills and experience to meet residents individual needs. EVIDENCE: Evidence confirmed that the staffing levels during the day and night met the dependency levels of the residents. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 23 One member of staff carries out waking duties and the second member of staff carries out waking duties from 8.30pm until 11.30am, then sleep in duties until 5.30am and finally waking duties until 7.30am. The manager who lives in the Convent, which is part of the home, is also available in an emergency. There is a night staff rota in place and all night staff have been provided with a new contact outlining their duties. A formal review of night staff is carried out every three months. Residents confirmed that support was available when they needed it: “I ring my bell and a carer appears to help me” The manager has improved the recruitment process and is now requesting all staff recruited by St Angela’s to have protection of vulnerable adults checks and criminal records checks before they commence working in the home. One permanent staff has been recruited since the last inspection and another member of staff is in the process of being recruited. Evidence confirmed that the home were following a thorough recruitment process. There arrangements in place for all permanent staff including cleaners and volunteers to undertake a POVA/ criminal bureau check through the umbrella organisation responsible for checking this information on behalf of St Angela’s. The sample of staff personnel files seen confirmed that staff receive induction training on appointment. They also receive regular training in the home on statutory subjects such as fire safety training, first aid, basic food hygiene and manual handling, and specialist training such as dementia care. Evidence confirmed that there were satisfactory arrangements in place to manage staff disciplinary and grievance proceedings. Advice is obtained from an external social care consultant company when necessary. The majority of training continues to be provided through a private company based in Birmingham and the training takes place within the home. Previous discussions have taken place with e he manager about the benefits of having training with other providers of services and staff on occasions so that the opportunity to network and share ideas of good practice is increased. From the information seen the staff team are progressing very well with NVQ 2 training and two members of staff have NVQ3. Staff consulted during the training spoke very positively about the training and support provided in the home. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35, 36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and staff continue to benefit from an experienced manager who has begun to encourage an open style management approach. This style of management continues to show signs of develop which ensures that communication with staff and residents continue to improve. Support to care staff has improved since the last inspection. The system in place now ensures that residents benefit from staffs that are appropriately supervised. There are good systems in place to ensure that resident’ financial interests and valuables are safeguarded by the homes record keeping, policies and procedures. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 25 Health and safety checks have improved since the last inspection. The systems in place ensure that the health, safety and welfare of residents and staff is promoted and protected at all times. EVIDENCE: The majority of residents and staff members spoke very highly of the manager and the support she provides to residents and the staff team. The management team has developed further since the last inspection. One of the sisters continues to deputise when the manager is away. There are also two senior care assistants in place. Consequently the manager is now able to delegate some of her responsibilities to other members of the management team. Staff confirmed this information during the inspection and confirmed that the manager was always available if they chose to discuss something they were concerned about. There was evidence in place to confirm that staff from ethnic minority groups continue to feel well supported and discrimination is not accepted in the home. Comments received from residents and relatives included: “It is all very well run by caring nuns and staff. I am very happy here”. “St Angela’s is well known in The Catholic Community for giving excellent care “ St Angela’s is extremely well run by Sister who is efficient and always welcoming. She takes a personal interest in everything and visits all residents regularly. The staff are very willing, diligent, courteous, caring and hard working. They are all happy in their work and morale is very good indeed. Their patience is out standing. The facilities management is of a high standard and any problems are dealt with quickly and efficiently. St Angela is an outstanding home. Evidence confirmed that staff team meetings now taking place on a regular basis and staff are now receiving formal supervision on a regular basis. Written evidence confirmed that the systems in place to safeguard residents’ finances and valuables were good. Staff and residents confirmed this information at the time of the inspection. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 26 The majority of health and safety checks including fire safety records and fire risk assessments were observed to be up to date and accurate. All staff including agency staff are now included in fire safety training. A discussion also took place about emergency planning including plans for evacuation. The manager demonstrated her understanding of such plans and how the home were currently reviewing the procedures in place. St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 27 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 1 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 6 Requirement The registered person shall keep under review and where appropriate revise the statement of purpose and the service users guide (This means that any reference to nursing care taking place unless provided by District nurses must be removed) This is an ongoing requirement which was made at the last Key inspection conducted on 11 May 2006 The registered person shall not provide accommodation to a service user at the care home unless so far as it shall have been practicable to do so – a) needs of the service user have been assessed by a suitably qualified or suitably trained person; b) b) the registered person has obtained a copy of the assessment Timescale for action 09/07/07 2. OP1 14 09/07/07 St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 29 c) c) there have been appropriate consultation regarding the assessment with the service user or a representative of the service user d) The registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare experienced (This must means that full needs assessment must be completed before a resident is admitted to the home. A review must be held 4 – 6 weeks after admission to ensure that the placement can meet that persons needs) This is an ongoing requirement which was made at the last Key inspection conducted on 11 May 2006 3 OP7 15 Unless it is impracticable to carry 09/07/07 out such consultation the registered person shall after consultation with the service user or a representative of his, prepare a written plan (The service users plan “) as to how the service users needs in respect of his health and welfare are to be met safety do so This means that a care plan must be compiled for all residents before they enter the home St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 30 This is an ongoing requirement which was made at the last Key inspection conducted on 11 May 2006 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 OP15 Good Practice Recommendations A review of the catering arrangements in place should be carried out to ensure that all residents needs are being met St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Angelas Clifton Down Convent DS0000026518.V334818.R01.S.doc Version 5.2 Page 32 - 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. 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