Inspection on 09/01/08 for St Angelas Convent

This inspection was carried out on 9th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Angelas Convent 10/05/07

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 Jill Cornelius Unannounced Inspection 9th January 2008 10:15 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.V355206.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.V355206.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.V355206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2007 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 £500 and £520 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.V355206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out over one day (unannounced). This unannounced inspection took place midweek between the hours of 10:15am and 6:15 pm. The visit was to follow up requirements and recommendations made at the last key inspection held on the 10th May 2007. Evidence was gathered from: Examining previous correspondence with the home including Regulation 37 (Death illness, other events notifications) and Regulation 26 monthly reports complied by the responsible individual, inspection reports, information from talking to/observing residents, talking to the manager/talking to the administrator/talking to and observing staff, talking to one visitor, talking to and case tracking four residents, examining records, policies and procedures. Prior to this visit to the home survey’s had been sent to all resident’s and their relatives by the Commission for Social Care Inspection. Comments from the 13 returned responses to the surveys are included in the report. The overall rating for St. Angela’s is Adequate. 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. Visitors are made very welcome and meals are well managed and provide daily variation, and good nutrition for people. 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. Residents’ benefit from living in a safe, comfortable, homely environment Staffing levels at night and during the day are satisfactory with a result that residents’ needs are met at all times There are good systems in place to ensuring residents’ financial interests and valuables, are safeguarded by the homes record keeping, policies and procedures. People living at St. Angela’s completed survey returns includes: ‘ I am treated with respect’. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 6 ‘ Staff are very kind and willing to assist me’. ‘St. Angel’s is a very good care home’. ‘ I am very satisfied’. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5 Quality in this outcome area is good. 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. The opportunity to review the suitability of the home for new residents has improved since the last inspection continued improvement must take place so that the potential for unplanned admissions are avoided. EVIDENCE: The statement of purpose and service users’ guide (called the residents guide in this home) were both examined. These had been last reviewed and updated in July 2007. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 9 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. The statement of purpose and service users’ guide were both examined. It was observed that they have know been updated. The manager explained that either her or the two senior carers are involved in the admission process. The majority of residents are self-funding. There are currently only two residents funded by Bristol City Council (Adult Community care Team). Evidence confirmed that for individuals who are self funding and without a care management assessment / care plan the home carries out a needs assessment (meeting the person in his/her own living environment or hospital where possible). Documentation to carry out this assessment has been developed and used since the last inspection. Evidence confirmed that for individuals referred through care management the registered manager obtains a summary of health and social services assessment / care plan. A sample of needs assessments seen confirmed that they were being conducted on new residents. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. Continued improvements in the care planing system since the last four 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 continues to ensure that residents’ mental health needs are met. The medication adminstration system is not wholly satisfactory. Further improvements in the storage system is required to ensure that there are safeguards in place to protect residents and staff at all times. EVIDENCE: St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 11 Evidence confirmed that the management team have spent a considerable amount of time developing the care planning, risk assessment and review systems. Four samples of care plans were seen. They are written in plain English and give detailed information about the care required for the individual residents. These needs were identified on the care plan and there was evidence of a risk assessment’s in place from the sample of records seen. The daily running records were found to be kept up to date showing evidence to confirm that there are ongoing plans in place to improve the care planning documentation. Care files do not have photographs of residents in place. Again 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 residents who are bedfast. During the inspection two residents’ were visited in their rooms and 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 has 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. Policies and procedures for receiving, storing, administering and disposing of medications are in place and meet with the current legislation. The receipt, administration, disposal and controlled drug records were up to date and in order. The pharmacist who supplies the medication also receives unwanted medication for disposal. It was noted that there was no examples of staff signatures on the front sheet of the medication files. A recommendation is made that this is undertaken. So any query can be tracked back to the administering staff member. Therefore protecting the receiver of medication. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 12 A few residents continue to be supported to self-administer medication. There are 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. It was noted that the keys for medication cupboards are hung along side the cupboards on all three floors. This arrangement needs to be reviewed, as there is a possibility of persons taking medications not prescribes to them. Req. A minimum / maximum temperature reading thermometer is in place to monitor the drug fridge temperature these were found to be in safe limits. All staff involved in the administering of medication has 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 by people living at St. Angela’s and included: “They are very attentive”. “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”. Relative survey comments included: “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 again 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.V355206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Following the last three inspections 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 well managed and provide daily variation, and good nutrition for people. Improvements of the catering arrangements have been made ensuring 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.V355206.R01.S.doc Version 5.2 Page 14 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. A dedicated member of staff spends time engaged in social activities with residents on a daily basis. It was noted during this inspection that further progress had been made with developing social activities for residents. It was pleasing to see that the communal dining room is now being used more frequently for residents to meet. Regular coffee mornings or tea parties are held and the manager said that following mass families and priests often join in with these events. There is opportunity for residents to enjoy ‘the daily coffee morning’. One resident stated that ‘it is very good because we can have a chat daily with everyone’. Activities on offer include ‘piano playing’, ‘sing songs’, ‘clothes sales’. There is also a TV in the dinning room. There is no 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 include: “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”. Written evidence to confirm these social activities are taking place was available in the residents’ and relatives survey comments and include: “I like long walks up and down the corridors/ coffee mornings / sitting in the garden reading”. “I enjoy the coffee mornings in the home and the Corner luncheon club at Clifton Cathedral”. “I take part if I feel like it “ “I do not want constant activities; I like books and watching TV”. One relative said, “the activity that means a lot to my mother is Daily Mass in the Chapel. That is her ministry”. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 15 Relatives confirmed that they were always made welcome in the home. Comments such as: “The staff are very kind and helpful to my … and I am made to feel very welcome when I visit”. “My … is very happy as St Angela’s and it is like a second home to me and my family. I am welcomed into the Convent at any time of the day or night”. One visitor spoken to during the inspection confirmed s/he was always made very welcome in the home and that the manager and staff were very helpful. Daily menus were also examined and they confirmed that variety and choice were available. This was confirmed by comments received from people living at St. Angela’s included: “The fish is delicious. I like all meals”. “The meals are delicious”. “I usually like the meals”. “I‘m not a very good eater at the best of times, so I don’t eat everything. But by ordinary standards the food is good.” “I always like the meals. I am …..years old and they say I eat better than any one else.” “I enjoy the food. We have plenty of it and varied meals”. “I can feed myself. I know from observation that those residents who cannot feed themselves are properly fed. The carers are very patient”. “My … says the food is good”. “My … has always said the food is excellent”. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 16 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 good. 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 are in place to ensure that residents are protected from abuse. 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. All residents who completed a survey indicated that they knew who to talk to if they were not happy and how to make a complaint. Comments included: St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 17 “I’ve never had cause to complain” “I would speak to matron” “We are well looked after here. Staff are very nice and we have nothing to complain about”. Relatives surveyed confirmed that they were aware of the home’s complaints policy and procedure. There has been one complaint since the last inspection of May 07. This has been concluded satisfactory. The home promotes staff training and education in the protection of vulnerable adults (POVA) on induction and by updates. This was confirmed by observing the training records for four staff members. 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). Staff spoken with understood the protection of vulnerable adults and the risks to the vulnerable person of abuse. Staff were also aware of the action they would need to take if any abusive behaviour came to their attention. The home holds or manages resident’s personal money if requested and proper records and ledgers are kept. Three random samples were checked and found to be correct. The Commission for Social Care Inspection receive regular notifications about residents’ welfare and health. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, well decorated and furnished. It provides a safe, peaceful environment for the residents. The standard of furnishing and décor is good to the benefit of residents. The bedrooms and communal room and facilities are suitable and well presented for their purpose and meet the resident’s needs. The standard of cleanliness is high. EVIDENCE: St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 19 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. 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 throughout with no offensive odours; people told us it is ‘always’ like this. 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 people living at St. Angela’s 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.V355206.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. 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 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.V355206.R01.S.doc Version 5.2 Page 21 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: “When I ring my bell and a carer appears to help me” 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. Two 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 to undertake a POVA/ criminal bureau check through the umbrella organisation responsible for checking this information on behalf of St Angela’s. It was highlighted that if volunteers were used in the home that they also would need to undertake a POVA/criminal bureau check. 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 the 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.V355206.R01.S.doc Version 5.2 Page 22 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, 33, 35, 36 and 38 Quality in this outcome area is (excellent, good, adequate or poor). 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 development to ensure that communication with staff and residents continue to improve. Support to care staff continues to improve 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. The systems in place now ensure that the health, safety and welfare of St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 23 residents and staff is promoted and protected at all times. EVIDENCE: The 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. There was a high degree of satisfaction expressed by residents/relative spoken with or from surveys. Based on the comments made and through the inspectors observation it is evident that the home is run in residents best interests and to ensure their needs are being met. 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” Evidence confirmed that staff team meetings now take 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.V355206.R01.S.doc Version 5.2 Page 24 Health and safety records showed that relevant inspections and maintenance has been carried out at the required intervals for the fire alarms and fire fighting equipment, hoists and lift. Fire safety records and fire risk assessments were observed to be up to date and accurate. All staff including agency staff are included in fire safety training. Safety certificates were available for gas and electrical services. The home’s insurance certificate and registration certificates were displayed. St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 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 x 3 x 3 3 x 3 St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The medication adminstration system is not wholly satisfactory. Further improvements in the storage system is required to ensure that there are safeguards in place to protect residents and staff at all times. It was noted that the keys for medication cupboards are hung along side the cupboards on all three floors. This arrangement needs to be reviewed, as there is a possibility of persons taking medications not prescribed to them. It was noted that there was no examples of staff signatures on the front sheet of the three medication files. This must be undertaken, so any query can be tracked back to the administering staff member. DS0000026518.V355206.R01.S.doc Version 5.2 Page 27 2 OP9 St Angelas Clifton Down Convent St Angelas Clifton Down Convent DS0000026518.V355206.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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