Inspection on 14/06/05 for St Angelas Convent

This inspection was carried out on 14th June 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.

Other inspections for this house

St Angelas Convent 09/01/08

St Angelas Convent 10/05/07

St Angelas Convent 11/05/06

St Angelas Convent 02/02/06

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 5 Litfield Place Clifton Bristol BS8 3LU Lead Inspector Sandra Gibson Unannounced 14 & 15 June 2005 12:30 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. St Angelas Clifton Down Convent Version 1.10 Page 3 SERVICE INFORMATION Name of service St Angelas Clifton Down Convent Address 5 Litfield Place Clifton Bristol BS8 3LU 0117 9735436 0117 9706844 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) Sisters of the Temple Sister Marie Louise Levern PC Care Home 23 Category(ies) of DE Dementia (3) registration, with number OP Old Age (20) of places St Angelas Clifton Down Convent Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate 3 persons with dementia, certificate will revert to 23 older persons when these persons leave. Date of last inspection 05 December 2004 Brief Description of the Service: St Angela’s Clifton Down Convent is operated by The Sisters of The Temple, a Roman Catholic religious order. 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, up to 3 of whom may have dementia. St Angela’s 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 is 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. St Angelas Clifton Down Convent Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Tuesday between the hours of 12.35am and 4.45pm and a follow up visit took place announced the next day between 9.15am and 10.15am. Evidence was gathered from: • Talking to residents • Talking to the manager and senior care assistant • Talking to a Visiting GP • Talking to staff • Talking to visitors • Observation • Looking at the premises • Records • Policies and procedures What the service does well: Prospective residents and their relatives are given the opportunity to find out whether St Angela’s is going to be provide suitable care and accommodation which reduces the risk of residents feeling unsettled on admission. The manager promotes and maintains residents’ health care needs and ensures that residents have access to health services to meet their assessed health care needs. Visitors and members of the local community are made very welcome which provides interest and stimulation to residents. Meals are well managed and provide daily variation, and good nutrition for people. A comfortable, clean, safe standard of accommodation is provided for the residents of St Angela’s. Staff have a good understanding of the residents’ support needs. This is evident from the positive relationships which have been formed between the staff, residents and resident’s visitors. St Angelas Clifton Down Convent Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Information provided to residents in the contract / statement of terms and conditions is not always clear. Therefore residents are not always as fully informed as they should be. Residents may move into St Angela’s without their needs being fully assessed which may result in some needs not being met. A small number of residents who require care as a result of mild dementia can be looked after at St Angela’s. However residents with more complex needs may not be met as a result of the style of the building, the isolation of the St Angelas Clifton Down Convent Version 1.10 Page 7 bedrooms, the inadequate waking staffing levels at night and the need for further specialist training for staff. Further attention needs to be given to the completion of care plans with residents and their representatives to ensure that residents’ emotional and mental health needs are identified and met. These shortfalls have a potential to place residents at risk. The medication administration system has improved but is still unsatisfactory and potentially put residents at risk. Residents who have been assessed as needing dementia care following admission may need increased opportunities to experience a more stimulating and varied life where various informal activities are regularly made available by experienced staff to reduce isolation and increase wellbeing. Progress needs to be made to inform relatives about the complaints procedure so they can act on behalf of residents where they feel appropriate Measures in place to ensure that residents are protected from abuse have improved since the last inspection. However further work and training by the Local Authority needs to be completed so that residents are better protected. Staff are employed in sufficient numbers during the day to meet the residents’ needs, but waking night staff cover does not meet the residents needs at night particularly with three residents who require dementia care. This situation may put residents at risk. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. Formal support systems needs to be offered to care staff through regular supervision so that the welfare of residents is better protected. The system for accessing records that must be available for an inspection is not satisfactory. It must be improved to support staff when the manager and Administrator are not available so that residents rights and best interests are safeguarded at all times. Fire safety training must improve for night staff so that the health safety and welfare of residents and staff are promoted and protected. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Angelas Clifton Down Convent Version 1.10 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 Standards Statutory Requirements Identified During the Inspection St Angelas Clifton Down Convent Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4,5 . Standard 6 is not appicable Information provided to residents in the contract / statement of terms and conditions is not always clear. Therefore residents are not always as fully informed as they should be. The needs of residents who require dementia care and have more complex difficulties may not be met as a result of the style of the building, the isolation of the bedrooms, the staffing levels at night and the need for further specialist training for staff. Prospective residents and their relatives are given the opportunity to find out whether St Angela ’s is going to be provide suitable care and accommodation which reduces the risk of residents feeling unsettled on admission. EVIDENCE: A sample of residents contracts / statement of terms and conditions were examined. These documents have recently been updated with the address and details of The Commission for Social Care Inspection. It was noted that the long stay contracts are satisfactory, but there are gaps in information for St Angelas Clifton Down Convent Version 1.10 Page 10 residents admitted for a period of respite care. For example one contract was not signed or dated by the manager or resident and the charge for the period of respite was not clear. The needs assessment documentation does not contain all the information required to carry out a full assessment. The format is a tick box style and does not encourage the person who carries out the assessment to obtain more details. There are currently three residents who require dementia care accommodated at St Angela’s. The inspector was informed that the three residents in question are not the residents who were named as part of the condition of the registration of the home . Consequently the Commission for Social Care Inspection needs written details of these residents so that the condition can be reviewed, updated and then removed once the residents are no longer accommodated in the home. The manager and the majority of staff have recently received training in working with older people who require dementia care. The manager told the inspector that she is trying to provide more one to one time with staff to residents with dementia in order to provide increased support and stimulation throughout the day. The inspector observed that residents can remain quite isolated in their bedrooms due to the fact that there is no communal lounge. There is also only one member of staff working at night unless there is an emergency or a resident who is ill requires increased support due to changing needs. Arrangements are then put in place for one of the live in sisters to provide that care. Residents confirmed that they or their relatives were given the opportunity to view St Angela’s and meet the manager and the staff before they moved into the home . Several residents also told the inspector that they already knew the home as they had lived in the local area or they had known residents who had previously been accommodated there. St Angelas Clifton Down Convent Version 1.10 Page 11 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) 7,8,9, Further attention needs to be given to the completition of care plans with residents and their represenatatives to ensure that residents’ emotional and mental health needs are identified and met. Shortfalls in thre care planning system mean that residents emotional and mental health needs may not be met. Residents’ health care needs are fully met, but the medication administration system although much improved is still unstaisfactory and potentially puts residents at risk. EVIDENCE: A sample of care plans seen did not include information on resident’s emotional and mental health needs. 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. St Angelas Clifton Down Convent Version 1.10 Page 12 A General Practitioner visiting several residents at the time of the inspection said that she was “very happy with care provided at St Angela’s”,” There are no problems that I am aware of and staff are always very helpful”. Two visitors confirmed that they are always contacted if their relative has an accident in the home or is admitted to hospital. The medication administration system was examined . The manager has recently delegated the task of managing this system to a member of staff who has recently been promoted. The inspector heard that there had been a few problems with communication with the Pharmacy as a result of three different community pharmacists being responsible for dispensing the medication to the home in the last eight months. In the next few weeks new medication administration records are due to be to be used in the home. It was observed that the quantity and amount of prescribed medication received into the home is not always recorded. It was also observed that there were several gaps in recording medication, including medication administered at night, and vitamins and cod liver oil supplied by families is held and administered to residents by staff but not accounted for. There are also a number of residents who are supported to self administer medication which is good practice. However, it was noted that there is not always a risk assessment completed to protect these residents. Lockable storage facilities are available in residents’ rooms St Angelas Clifton Down Convent Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,and 14 Residents who have been assessed as needing dementia care following admission may need increased opportunities to experience a more stimulating and varied life where various informal activities are regularly made available by experienced staff to reduce isolation and increase wellbeing. Visitors and members of the local community are made very welcome which provides interest and stimulation to residents. Meals are well managed and provide daily variation, and good nutrition for people. EVIDENCE: St Angela’s provides a quiet lifestyle for residents where very few communal activities take place. This is satisfactory for the majority of residents as they have been fully informed about the lifestyle prior to the admission and this is their preference. Two visitors told the inspector that they felt that there was a lack of social activities provided in the home and that residents who are able choose to go out with their family or friends or have regular visitors to the home . They told the inspector that their relative may have chosen that lifestyle when she St Angelas Clifton Down Convent Version 1.10 Page 14 was first admitted to the home, but when she became more frail she also became more isolated and now never leaves her bedroom. It was their opinion that there was no choice available for residents to join in with activities in the home. Two residents confirmed this information. One resident told the inspector that she preferred to stay in her room where she could receive visitors or to go out with family and friends. She explained that this is one of the reasons why she chose to move to St Angela’s. Another resident said that she knew the situation when she moved in, but did feel lonely at times despite regular visitors from friends and occasional visits from family members. The inspector observed that the three residents who required dementia care were being cared for in their rooms. On the day of the inspection there was no sign of activities taking place outside their bedrooms. It was noted that one resident had fallen the day before and had an injured hand which needed medical attention. The inspector noted that the General Practitioner was attending to the resident on the day of the inspection and that arrangements were made for the resident to be admitted to Accident and Emergency for an assessment. The manager told the inspector that following the last inspection she had allocated one member of staff each day to spend more time engaged in social activities with residents particularly those residents who require dementia care. The manager said that she encouraged activities such as talking to residents about their interests, escorting residents to the garden and reading to them. There were no records in place to confirm these activities were taking place. Two visitors confirmed that they were always made very welcome in the home by the manager and staff team who were very good at passing information on about their relative when they visited or by telephone. One visitor who had been a resident herself and was visiting another resident she had made friends with said that she had enjoyed her stay in the home and that she had been well looked after. Another visitor from the Cathedral said he was always made very welcome in the home and that the manager and staff were very approachable. Two residents consulted said that the meals were very good and that the staff listen to their choices. Both residents confirmed that they prefer to eat in the privacy of their own room rather that the dinning room which is only used by residents on special days such as Christmas Day. St Angelas Clifton Down Convent Version 1.10 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a satisfactory complaints system in place with some evidence that residents feel that their views are listened too. However, progress needs to be made to inform relatives about the complaints procedure so they can act on behalf of residents where they feel appropriate Measures in place to ensure that residents are protected from abuse have improved since the last inspection. However further work and training by the Local Authority needs to be completed so that residents are better protected. EVIDENCE: There have been no new complaints since the last inspection. Three residents consulted confirmed that they were aware of the complaints procedure and that they knew who to speak to if they had any concerns. Two visitors told the inspector that if they had any concerns then they would speak to the manager. However they had never formally been informed of the complaints procedure. Following the last inspection an additional visit was made by the inspector in order to follow up an allegation of abuse made by a resident that had not dealt with according to the Local Authority Adult Protection procedure despite the manager and the majority of staff members receiving adult protection training. St Angelas Clifton Down Convent Version 1.10 Page 16 The outcome of this visit was to organise a meeting between the Local Authority Adult Protection Coordinator, the manager, the responsible individual for the home and The Commission for Social Care Inspection. This meeting took place in April 2005 and the outcome of the meeting was for the Adult Protection Coordinator to offer guidance to the manager to review the Adult Protection policy and procedure in the home to ensure that it was in line with the Local Authority Adult Protection Procedure (No Secrets in Bristol) and to review the physical restraint . During this inspection the manager informed the inspector that this meeting had not yet taken place to date, but she would be contacting the Adult Protection Coordinator after the inspection. Consequently, the Adult Protection Policy and Procedure in place has not been reviewed as required at the last inspection. This requirement is therefore outstanding and the timescale will be extended. It was noted that abuse had been discussed at the first staff meeting that has taken place in recent months. The inspector observed that some misleading information had been recorded in the minutes about staff “checking with Sister or the Person in Charge about whether details should be recorded or not “.This information is confusing for staff as all details of any allegations must be recorded, but not investigated by the care staff. It was pleasing however to note that The Commission for Social Care Inspection are now receiving regular notifications about residents’ welfare and health. This practice has improved greatly since the last inspection. St Angelas Clifton Down Convent Version 1.10 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 A comfortable, clean, safe standard of accommodation is provided for the residents of St Angela’s EVIDENCE: In general, the environment is well maintained and suited to the majority of residents needs residents needs. However, as discussed earlier in the report. Residents spend the majority of time in their bedrooms. There is a communal dining area and reception area which are used very infrequently by residents This accommodation may be isolating for residents who need the company and stimulation of other residents and frequent contact with staff. Disabled access is through a ramp at the front of the building. St Angela’s is decorated and furnished to a standard that creates a comfortable homely atmosphere. There is a programme of redecoration and refurbishment to further improve the environment St Angelas Clifton Down Convent Version 1.10 Page 18 Residents bedrooms looked homely and were personalised with residents personal possessions and furniture. Two residents seen at the time of the inspection spoke very positively about bringing their own furniture and belongings to the home. The toilet and bathroom facilities are sufficient to meet the needs of the residents. There were no unpleasant smells in the home and the rooms were cleaned to a high standard St Angelas Clifton Down Convent Version 1.10 Page 19 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, 29,30 Staff have a good understanding of the resident support needs. This is evident from the positive relationships which have been formed between the staff and residents. Staff are employed in sufficient numbers during the day to meet the residents needs, but waking night staff cover does not meet the residents needs at night particularly with three residents who require dementia care. This situation may put residents at risk. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. Staff training has improved over the last year with the result that residents benefit from a more competent, trained staff team. EVIDENCE: The residents and visitors spoken to during the inspection spoke very highly about the manager and the staff team . Comments such as “ The staff will do anything for you “ and ” It is very good here – you get well looked after”. Staff were also observed speaking to residents with respect and dignity. The staffing levels during the day were noted to meet the dependency levels of the residents. However, it was noted that there was only one waking member of staff at night for twenty three residents, three of which require dementia care. It was also noted that the layout of the home is over three floors which St Angelas Clifton Down Convent Version 1.10 Page 20 makes it impossible for a staff member to know what is happening on each level. One resident told the inspector that she used an emergency alarm at night to call for support. She told the inspector she could not sleep so had wanted to ask the member of staff on duty for a sleeping tablet. The resident said that she waited but there was no response in her estimation for thirty minutes. She told the inspector that she thought the night staff member was busy with a resident who requires extra support as a result of dementia, so she turned off the alarm and tried to go to sleep without the medication. The manager and senior carer were aware of the situation and told the inspector that the period of time was less than thirty minutes and the member of staff had gone to the assistance of the resident, but found she had gone to sleep. The manager explained that herself and several of the other sisters who provide care take turns to assist at nights in an emergency ie when somebody is ill or a resident’s dependency levels increases. However there is no regular second waking staff member at night. Staff have to wake up one of the sisters if they need help. This is not a satisfactory situation and needs to be improved. Two staff files were examined and it was noted there was no application or written references in place for either of these members of staff . The inspector was informed by the manager that both staff members had been recruited through an agency, one in October 2002 and the other in April 2004. An up to date criminal records bureau check was seen for one staff member, but not for the other. This information was confirmed by both staff members who thought that they had completed an application and that references has been requested. The second criminal records bureau check was later sent to the Commission for Social Care Inspection. This check had been carried out by the agency and not by St Angela’s. All staff employed by the care home must have a criminal records bureau check and POVA check completed by the care home before they are employed. 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. From the information seen the staff team are progressing well towards 50 of staff having completed NVQ 2 training in 2005. St Angelas Clifton Down Convent Version 1.10 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36,37,38 The residents and staff team benefit from an experienced manager who has began to encourage an open style management approach which improves communication for staff and residents. Support to care staff is improving with the re introduction of staff meetings. However, further formal support systems needs to be offered to care staff through regular supervision. The system for accessing records that must be available for an inspection is not satisfactory. It must be improved to support staff when the manager and administrator are not available so that residents rights and best interests are safeguarded at all times. Fire safety training must improve for night staff so that the health safety and welfare of residents and staff are promoted and protected. St Angelas Clifton Down Convent Version 1.10 Page 22 EVIDENCE: All residents and staff members consulted spoke very highly of the manager and the support she provides to the residents and staff team. The management team has developed since the last inspection. One of the Sisters acts as deputy when the manager is away and a senior carer has recently been appointed to support the manager with management tasks such as the medication administration system. Two members of staff consulted told the inspector that they had been observed through shadow working when they started in post. The manager has recently re introduced team meetings. The first of these meetings was held on May 9th and minutes were recorded. Neither member of staff interviewed had received formal supervision. However, one member of staff who had been in post more that an year had undergone an appraisal of her work The fire log was examined; it was noted that the fire safety training was not up to date . The last fire safety training and fire drills recorded was June 2004. The manager informed the inspector that fire safety training and a fire drill had taken place for all members of staff in January 2005. It was noted that care staff who work at night or sleep in the home do not receive three monthly fire safety training This information was confirmed when it was sent to the Commission for Social Care Inspection following the inspection. There was also no fire risk assessment available for inspection. This information was also forwarded to the Commission for Social Care Inspection after the inspection. St Angelas Clifton Down Convent Version 1.10 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 x x x 1 2 1 St Angelas Clifton Down Convent Version 1.10 Page 24 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. Standard OP2 Regulation 5(1)(b) Requirement All persons admitted to the home must be provided with a written contract /statement of terms and conditions No person should be admtted to the home unless their needs have been fully assessed by a suitably trained person The manager must review the provision of care, treatment and supervision of the three residents who require dementia care A written care plan which includes residents emotional and mental health needs must be drawn up following consulatation with the resident or representative where appropriate The manager must improve the arrangements for the recording , handling , safekeeping , safe administration and disposal of medicines received into the care home Residents interests must be recorded and they must be given the opportunity for stimulation through leisure and recreational activities both inside and outside the home which Version 1.10 Timescale for action 15th July 2005 15th July 2005 31st July 2005 2. OP3 14(1)(a) 3. OP4 12(b) 4. OP7 15 31st July 2005 5. OP9 13(2) 31st July 2005 6. OP12 16(2) 30th August 2005 St Angelas Clifton Down Convent Page 25 7. OP18 13(6) 8. OP27 18(1)(a) 9. OP29 19 10. 11. OP36 OP37 18(2) 17 12. 13. OP38 23(4)(e) suits the needs of all residents, but particular consideration is given to residents with dementia Following consultation with the Local Authorities Adult Protection Coordinator the manager must review the homes Adult Protection Policy and Procedure to ensure that it icomplies with e with NO Secrets in Bristol(Local Authority Adult Protection Procedure) There must be two waking staff at night to ensure that residents dependency needs can be met including the three residents with dementia) in a home that is located on three levels Before a person is employed to work in the care home the manager must ensure that there are the following documentation in place: Proof of the persons identity,the persons birth certificate , the persons current passport (ifany) , documentary evidence of any relevant qualifications, two written references , evidence that the person is physically and mentally fit for the job, declartion of any criminal offences, a CRB check and POVA check conducted by the care home All care staff must receive formal supervision at least six times a year All records required for inspection (Schedule 3 and 4) must be kept up to date and made available at all times for inspection All staff who work at night or sleep in the home must receive three monthly fire safety training 31st July 2005 30th August 2005 31st July 2005 31st December2 005 31st July 2005 31st July 2005 St Angelas Clifton Down Convent Version 1.10 Page 26 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. 3. Refer to Standard 16 Good Practice Recommendations Ensure that all relatives as well as residents have access to the homes complaints procedure St Angelas Clifton Down Convent Version 1.10 Page 27 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 St Angelas Clifton Down Convent Version 1.10 Page 28 - 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!